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Saglam A, Derwig I, Gul M, Kasap B, Yilmaz N, Sezik M, Celik O, Tiryaki S, Özcil MD, Sipahioğlu H, İnci S, Demircan F. Foetal cardiac function in third trimester pregnancies with reduced fetal movements. J OBSTET GYNAECOL 2021; 42:28-34. [PMID: 33938348 DOI: 10.1080/01443615.2020.1869706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The objective of our study was to investigate the possible relationship between poor perinatal outcome and foetal cardiac functions in pregnant women with reduced foetal movements (RFM). This cross-sectional study included 126 pregnant women with normal foetal movements (Group 1, Controls) and 42 pregnant women over 32 weeks gestation with RFM (Group 2). Group 2 was further divided into two subgroups according to their perinatal outcome: normal perinatal outcome (Group 2a) and poor perinatal outcome (Group 2b). Cardiotocography, the E/A ratio in both atrioventricular valves, myocardial performance index (MPI) and foetal tricuspid annular plane systolic excursion (f-TAPSE) were evaluated. Foetuses with poor perinatal outcome had a higher MPI (p = .003), higher tricuspid and mitral E/A (p < .001), and lower f-TAPSE values (p < .001). In regression analysis, f-TAPSE was the only parameter (p = .04) independently associated with poor perinatal outcome. İn conclusion, examining f-TAPSE may predict adverse perinatal outcome in pregnancies with RFM.IMPACT STATEMENTWhat is already known on this subject? Reduced foetal movement (RFM) is associated with adverse pregnancy outcome. Cardiotocography, amniotic fluid assessment, estimated birthweight, foetal Doppler and formal foetal movement count (kick chart) are generally used in the clinical assessment of pregnancies with reduced foetal movements. These tests, we currently use to assess foetal wellbeing in women with reduced foetal movements, have limited sensitivity in predicting foetal compromise.What do the results of this study add? Foetal cardiac Doppler may potentially be used as an important adjunct to the conventional management of women with a perception of reduced foetal movements.What are the implications of these findings for clinical practice and/or further research? Foetal echocardiographic evaluation, such as f-TAPSE, may influence clinical practice by enabling improved risk stratification for poor perinatal outcome, thus allowing more timely definitive intervention. This could help to decrease the rate of stillbirth related to reduced foetal movements. The few established echocardiographically derived parameters, which can asses global right ventricle function, are not always easy to obtain, however, f-TAPSE is easily obtainable using ultrasound and it appears to be a clinically useful echocardiographic measurement of right ventricular function.
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Affiliation(s)
- Aylin Saglam
- Department of Obstetrics and Gynecology, Aksaray University School of Medicine, Aksaray, Turkey
| | - Iris Derwig
- Chelsea Westminster Hospital NHS Foundation Trust, London, England
| | - Murat Gul
- Department of Cardiology, Aksaray University School of Medicine, Aksaray, Turkey
| | - Burcu Kasap
- Department of Obstetrics and Gynecology, Mugla Sıtkı Koçman University, Muğla, Turkey
| | - Nuh Yilmaz
- Department of Pediatric Cardiology, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Mekin Sezik
- Department of Obstetrics and Gynecology, Department of Perinatology, Isparta Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Onder Celik
- Private Clinic Obstetrics and Gynecology, Usak, Turkey
| | - Sibel Tiryaki
- Department of Pediatric Cardiology, Mugla Sıtkı Koçman University, Muğla, Turkey
| | - Mustafa Doğan Özcil
- Department of Obstetrics and Gynecology, Hatay Mustafa Kemal University, Hatay, Turkey
| | - Haydar Sipahioğlu
- Department of Obstetrics and Gynecology, Aksaray University School of Medicine, Aksaray, Turkey
| | - Sinan İnci
- Department of Cardiology, Aksaray University School of Medicine, Aksaray, Turkey
| | - Fadime Demircan
- Department of Obstetrics and Gynecology, Uskudar Yunus Emre Hospital, Istanbul, Turkey
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Utility of prenatal Doppler ultrasound to predict neonatal impaired cerebral autoregulation. J Perinatol 2018; 38:474-481. [PMID: 29410542 DOI: 10.1038/s41372-018-0050-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 12/06/2017] [Accepted: 01/02/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Determine if abnormal prenatal Doppler ultrasound indices are predictive of postnatal impaired cerebral autoregulation. STUDY DESIGN Prospective cohort study of 46 subjects, 240-296 weeks' gestation. Utilizing near-infrared spectroscopy and receiver-operating characteristic analysis, impaired cerebral autoregulation was defined as >16.5% time spent in a dysregulated state within 96 h of life. Normal and abnormal Doppler indices were compared for perinatal outcomes. RESULTS Subjects with abnormal cerebroplacental ratio (n = 12) and abnormal umbilical artery pulsatility index (n = 13) were likely to develop postnatal impaired cerebral autoregulation (p ≤ 0.02). Abnormal cerebroplacental ratio was associated with impaired cerebral autoregulation between 24 and 48 h of life (p = 0.016). These subjects have increased risk for fetal growth restriction, lower birth weight, lower Apgar scores, acidosis, and severe intraventricular hemorrhage and/or death (p < 0.05). CONCLUSION Abnormal cerebroplacental ratio and umbilical artery pulsatility index are associated with postnatal impairment in cerebral autoregulation and adverse outcome.
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Seravalli V, Block-Abraham D, McShane C, Millard S, Baschat A, Miller J. Aortic isthmus shunt dynamics in normal and complicated monochorionic pregnancies. Prenat Diagn 2017; 37:924-930. [PMID: 28695721 DOI: 10.1002/pd.5115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To study fetal aortic isthmus (AoI) shunt dynamics in monochorionic (MC) twins. METHODS Normal and complicated MC pregnancies were prospectively enrolled. The relationship of isthmus flow index (IFI) with Doppler parameters of umbilical artery (UA), descending aorta, middle cerebral artery, and ductus venosus and with left and right ventricular cardiac output and stroke volume was studied. RESULTS The IFI was obtained in 180 examinations from 48 pregnancies (24 twin-twin transfusion syndrome, TTTS; 4 selective intrauterine growth restriction, sIUGR; 12 TTTS + sIUGR; and 8 uncomplicated). Median gestational age was 20.9 weeks. AoI diastolic flow was reversed in three cases. UA pulsatility index (PI) and ductus venosus-PI z-scores were negatively correlated with the IFI (rs -0.40 and -0.26, respectively, p < 0.001). Regression analysis identified only UA-PI as a determinant of the IFI (p < 0.001). The IFI was significantly correlated with left ventricular cardiac output and stroke volume. It did not differ between TTTS donors and recipients. sIUGR fetuses had significantly lower IFI compared with normal-grown counterparts (p < 0.001). CONCLUSION In MC gestations, AoI shunting is predominantly determined by placental flow resistance, while cerebral impedance and volume status have no impact. In MC twins, the relationship between AoI flow and outcome deserves further study in the setting of sIUGR. © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Viola Seravalli
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dana Block-Abraham
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cyrethia McShane
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Millard
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jena Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ali E, Kumar M, Naqvi SE, Trivedi SS, Singh A. Fetal vascular adaptation before and after treatment of severe maternal anemia in pregnancy. Int J Gynaecol Obstet 2016; 133:284-6. [DOI: 10.1016/j.ijgo.2015.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 11/05/2015] [Accepted: 02/05/2016] [Indexed: 10/22/2022]
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Gámez F, Rodríguez MJ, Tenías JM, García J, Pintado P, Martín R, Pérez R, Ortiz-Quintana L, De León-Luis J. Reference ranges for the pulsatility index of the fetal aortic isthmus in singleton and twin pregnancies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:577-584. [PMID: 25792572 DOI: 10.7863/ultra.34.4.577] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES The purpose of this study was to estimate reference ranges for the pulsatility index (PI) of the fetal aortic isthmus in uncomplicated singleton and twin pregnancies during the second half of pregnancy. METHODS We conducted a cross-sectional observational study involving 543 healthy fetuses: 361 singleton pregnancies and 182 twin pregnancies between 19 and 36 weeks' gestation. The aortic isthmus PI was measured in 2 sonographic planes: the longitudinal aortic arch view and the 3-vessel and trachea view. We evaluated the reproducibility of aortic isthmus PI measurements between these planes by calculating intraclass correlation coefficients and limits of agreement. Scans were performed by 2 physicians, and intraobserver agreement was also measured. Regression analysis was used to estimate gestational age reference values for the aortic isthmus PI. RESULTS The aortic isthmus PI was significantly correlated with gestational age in singletons and twins during the second half of pregnancy (P < .01). We did not find significant differences between reference ranges in singletons and twins or between the sonographic views. CONCLUSIONS This study offers reference ranges for the aortic isthmus PI during the second half of gestation in singleton and twin pregnancies. Mean aortic isthmus PI values were similar in both types of gestations as well as both sonographic views. The aortic isthmus PI may be reliably obtained from either sonographic view.
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Affiliation(s)
- Francisco Gámez
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - María José Rodríguez
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - José María Tenías
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Javier García
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Pilar Pintado
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Raquel Martín
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Ricardo Pérez
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Luis Ortiz-Quintana
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Juan De León-Luis
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain (F.G., P.P., R.M., R.P., L.O.-Q., J.D.L.-L.); and Department of Obstetrics and Gynecology (M.J.R., J.G.) and Research Support Unit (J.M.T.), Hospital la Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain.
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Chabaneix J, Fouron JC, Sosa-Olavarria A, Gendron R, Dahdah N, Berger A, Brisebois S. Profiling left and right ventricular proportional output during fetal life with a novel systolic index in the aortic isthmus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:176-181. [PMID: 24585706 DOI: 10.1002/uog.13345] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Revised: 01/07/2014] [Accepted: 02/14/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Left ventricular ejection causes forward flow in the fetal aortic isthmus while the right ventricle has a retrograde influence. The aim of this study was to create reference values for an isthmic systolic index (ISI) reflecting the changing influence of right and left ventricular performance on Doppler flow velocity waveforms of the aortic isthmus throughout normal pregnancy. METHODS Doppler recordings of 260 normal fetuses with a gestational age of 18-37 weeks were reviewed. Peak systolic velocity (PSV) and end-systolic velocity (or systolic nadir; Ns) were measured on all aortic isthmus waveforms. An ISI was derived from the ratio Ns/PSV. Left and right ventricular outputs were also calculated. RESULTS Up to 22-23 weeks' gestation, the mean ISI is stable at around 0.2. At about 28 weeks, a brief end-systolic deceleration wave is observed on the aortic isthmus waveforms, progressing steadily with gestation and causing a fall of ISI towards a mean value of zero between 30 and 31 weeks. This trend continues thereafter and a mean value of -0.4 was observed at the end of pregnancy. An inverse correlation was found between right ventricular output and Ns (r = -0.334, P = 0.001). Simultaneous recordings of the isthmus and the ductus arteriosus Doppler waveforms demonstrated that the primary cause of the end-systolic deceleration and ultimate reversal of flow at the isthmus is the increasingly dominant flow from the right ventricle. CONCLUSION The transitional changes of the respective right and left ventricular outputs throughout pregnancy are well profiled by the ISI. This index highlights the physiological increase in fetal right ventricle flow preponderance as pregnancy progresses. Alteration of the ISI profile could be expected in clinical conditions associated with unbalanced alteration of the fetal ventricular outputs.
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Affiliation(s)
- J Chabaneix
- Fetal Cardiology Unit, Pediatric Cardiology Division, CHU Sainte-Justine, University of Montreal, Quebec, Canada
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Garcia-Canadilla P, Rudenick PA, Crispi F, Cruz-Lemini M, Palau G, Camara O, Gratacos E, Bijens BH. A computational model of the fetal circulation to quantify blood redistribution in intrauterine growth restriction. PLoS Comput Biol 2014; 10:e1003667. [PMID: 24921933 PMCID: PMC4055406 DOI: 10.1371/journal.pcbi.1003667] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 04/24/2014] [Indexed: 11/18/2022] Open
Abstract
Intrauterine growth restriction (IUGR) due to placental insufficiency is associated with blood flow redistribution in order to maintain delivery of oxygenated blood to the brain. Given that, in the fetus the aortic isthmus (AoI) is a key arterial connection between the cerebral and placental circulations, quantifying AoI blood flow has been proposed to assess this brain sparing effect in clinical practice. While numerous clinical studies have studied this parameter, fundamental understanding of its determinant factors and its quantitative relation with other aspects of haemodynamic remodeling has been limited. Computational models of the cardiovascular circulation have been proposed for exactly this purpose since they allow both for studying the contributions from isolated parameters as well as estimating properties that cannot be directly assessed from clinical measurements. Therefore, a computational model of the fetal circulation was developed, including the key elements related to fetal blood redistribution and using measured cardiac outflow profiles to allow personalization. The model was first calibrated using patient-specific Doppler data from a healthy fetus. Next, in order to understand the contributions of the main parameters determining blood redistribution, AoI and middle cerebral artery (MCA) flow changes were studied by variation of cerebral and peripheral-placental resistances. Finally, to study how this affects an individual fetus, the model was fitted to three IUGR cases with different degrees of severity. In conclusion, the proposed computational model provides a good approximation to assess blood flow changes in the fetal circulation. The results support that while MCA flow is mainly determined by a fall in brain resistance, the AoI is influenced by a balance between increased peripheral-placental and decreased cerebral resistances. Personalizing the model allows for quantifying the balance between cerebral and peripheral-placental remodeling, thus providing potentially novel information to aid clinical follow up. Intrauterine growth restriction (IUGR) is one of the leading causes of perinatal mortality and can be defined as a low birth weight together with signs of chronic hypoxia or malnutrition. It is mostly due to placental insufficiency resulting in a chronic restriction of oxygen and nutrients to the fetus. IUGR leads to cardiac dysfunction in utero which can persist postnatally. Under these altered conditions, IUGR fetuses redistribute their blood in order to maintain delivery of oxygenated blood to the brain, known as brain sparing. Given that, in the fetus the aortic isthmus (AoI) is a key arterial connection between the cerebral and placental circulations, quantifying AoI blood flow has been proposed to assess this brain sparing effect in clinical practice. However, which remodeling or redistribution processes in the cardiovascular systems induce the observed changes in AoI flow in IUGR fetuses is not fully understood. We developed a computational model of the fetal circulation, including the key elements related to fetal blood redistribution. Using measured cardiac outflow profiles to allow personalization, we can recreate and better understand the blood flow changes in individual IUGR fetuses.
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Affiliation(s)
- Patricia Garcia-Canadilla
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Physense, DTIC, Universitat Pompeu Fabra, Barcelona, Spain
- * E-mail:
| | - Paula A. Rudenick
- University Hospital and Research Institute Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Fatima Crispi
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Monica Cruz-Lemini
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Georgina Palau
- Physense, DTIC, Universitat Pompeu Fabra, Barcelona, Spain
| | - Oscar Camara
- Physense, DTIC, Universitat Pompeu Fabra, Barcelona, Spain
| | - Eduard Gratacos
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Bart H. Bijens
- Physense, DTIC, Universitat Pompeu Fabra, Barcelona, Spain
- ICREA, Barcelona, Spain
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Acharya G, Tronnes A, Rasanen J. Aortic isthmus and cardiac monitoring of the growth-restricted fetus. Clin Perinatol 2011; 38:113-25, vi-vii. [PMID: 21353093 DOI: 10.1016/j.clp.2010.12.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aortic isthmus acts as an arterial watershed between the cerebral and placental circulations, connecting 2 parallel fetal ventricular pumps. It plays a crucial role in the fetal circulatory dynamics. Information about aortic isthmus blood flow may improve the management of sick fetuses. However, perceived technical difficulties limit the clinical use of aortic isthmus Doppler for fetal hemodynamic monitoring. Changes in aortic isthmus blood flow pattern seem to reflect fetal cardiovascular status accurately and predict perinatal and long-term neurodevelopmental outcome in intrauterine growth restriction. This review evaluates the available scientific information and discusses the role of aortic isthmus in fetal circulation.
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Affiliation(s)
- Ganesh Acharya
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Sykehusveien 38, N-9038 Tromsø, Norway
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Causes and mechanisms of intrauterine hypoxia and its impact on the fetal cardiovascular system: a review. Int J Pediatr 2010; 2010:401323. [PMID: 20981293 PMCID: PMC2963133 DOI: 10.1155/2010/401323] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 08/04/2010] [Accepted: 09/16/2010] [Indexed: 11/17/2022] Open
Abstract
Until today the role of oxygen in the development of the fetus remains controversially discussed. It is still believed that lack of oxygen in utero might be responsible for some of the known congenital cardiovascular malformations. Over the last two decades detailed research has given us new insights and a better understanding of embryogenesis and fetal growth. But most importantly it has repeatedly demonstrated that oxygen only plays a minor role in the early intrauterine development. After organogenesis has taken place hypoxia becomes more important during the second and third trimester of pregnancy when fetal growth occurs. This review will briefly adress causes and mechanisms leading to intrauterine hypoxia and their impact on the fetal cardiovascular system.
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Degani S. Evaluation of fetal cerebrovascular circulation and brain development: the role of ultrasound and Doppler. Semin Perinatol 2009; 33:259-69. [PMID: 19631086 DOI: 10.1053/j.semperi.2009.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The human fetal brain is protected from pressure changes by autoregulation of the cerebral circulation. However, antenatal intrauterine cerebrovascular events are found to play an important role in the pathogenesis of perinatal brain damage. Changes in placental vascular resistance, cardiac contractibility, vessel compliance, and blood viscosity alter the normal dynamics of fetal cerebral circulation. The introduction of various sonographic techniques and the collection of data from the arterial and venous cerebral circulation provide a powerful tool for the evaluation of physiological and pathological hemodynamic events. Anatomic and physiological considerations of cerebral vasculature in healthy and disease states are relevant in studying brain development and variations in fetal brain blood perfusion. The major role of ultrasound and Doppler modalities in the evaluation of fetal cerebrovascular circulation is enabled by implementation of these considerations. Changes in flow characteristics in fetal cerebral vasculature can be used for clinical decision making in situations of fetal compromise, such as growth restriction and anemia.
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Affiliation(s)
- Shimon Degani
- Department of Obstetrics and Gynecology, Bnei Zion Medical Center, Ruth and Baruch Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.
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Acharya G. Technical aspects of aortic isthmus Doppler velocimetry in human fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:628-633. [PMID: 19479680 DOI: 10.1002/uog.6406] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- G Acharya
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, University of Tromsø and University Hospital of Northern Norway, Tromsø, Norway.
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Vimpeli T, Huhtala H, Wilsgaard T, Acharya G. Fetal aortic isthmus blood flow and the fraction of cardiac output distributed to the upper body and brain at 11-20 weeks of gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 33:538-544. [PMID: 19350568 DOI: 10.1002/uog.6354] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To measure serial changes in fetal aortic isthmus (AI) blood flow and estimate the fraction of fetal cardiac output distributed to the upper body, including the brain, at 11-20 weeks of gestation. METHODS Using pulsed-wave Doppler and two-dimensional ultrasound, blood flow velocities and inner diameter of the AI, aortic valve (AV) and pulmonary valve (PV) were measured longitudinally in 143 fetuses and volume blood flows (Q) were calculated for each site using the formula: Q (mL/min) = pix (diameter/2)(2) x velocity time integral x heart rate x 60. The sum of Q(av) and Q(pv) constituted the combined cardiac output (CCO) and the fraction (%) of the upper body (including brain) blood flow was calculated as: (Q(av)-Q(ai))x100/CCO. RESULTS AI blood velocities as well as the vessel diameter increased with advancing gestation, resulting in a significant increase in Q(ai) from 1.9 to 40.5 mL/min during weeks 11 to 20. The AI peak systolic velocity increased from 29 to 63 cm/s, end-diastolic velocity from 1.2 to 5.2 cm/s, and the time-averaged maximum velocity from 11 to 22 cm/s, resulting in a fairly stable pulsatility index (PI) of 2.4-2.6 and resistance index (RI) of 0.91-0.94. On average, 75% of blood ejected by the left ventricle (which represented about 35% of the CCO) passed through the AI to the descending aorta. The fraction of CCO distributed to the upper body, including the brain, was estimated as approximately 13%. CONCLUSION We have established longitudinal reference ranges for fetal AI diameter, blood flow velocities, PI, RI and volume blood flow at 11-20 weeks of gestation. The human fetus appears to direct a relatively small fraction (13%) of its CCO to the upper body, including the brain, during this period of pregnancy.
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Affiliation(s)
- T Vimpeli
- The Central Maternity Unit, City of Tampere, Finland
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Fouron JC. [Blood flow through the fetal aortic isthmus: a new physiological concept with many clinical implications]. Med Sci (Paris) 2007; 23:950-6. [PMID: 18021706 DOI: 10.1051/medsci/20072311950] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
UNLABELLED The new physiological concept: because of the parallel disposition of the fetal ventricles and of their respective arterial outlet, the flow through the aortic isthmus represents the only arterial shunt in the fetal circulation. The low resistance of the placental circulation explains the forward systolic and diastolic flows normally observed through the isthmus. CLINICAL IMPLICATIONS (1) assessment of individual performances of each ventricle : left ventricle causes forward flow while the right ventricle has a retrograde influence; (2) any changes of flow and/or resistances affecting one of the two fetal arterial systems organized in parallel should influence the flow pattern within the isthmus. Examples : peripheral arterio-venous fistula, increase in placental vascular resistance leading to intra-uterine growth restriction, etc. CONCLUSION doppler flow recordings in the fetal aortic isthmus: (1) provides information on the global condition of the fetal cardiocirculatory system; (2) is a good indicator of fetal individual ventricular performance; (3) allows assessment of hemodynamic consequences of abnormalities of the peripheral circulatory systems.
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Affiliation(s)
- Jean-Claude Fouron
- Unité de Cardiologie Foetale, Service de Cardiologie, CHU Sainte-Justine, 3175, chemin de la Côte Sainte-Catherine, Montréal, Québec H3T 1C5, Canada.
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Del Río M, Martínez JM, Figueras F, Bennasar M, Palacio M, Gómez O, Coll O, Puerto B, Cararach V. Doppler assessment of fetal aortic isthmus blood flow in two different sonographic planes during the second half of gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2005; 26:170-4. [PMID: 16041679 DOI: 10.1002/uog.1955] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To compare the reliability of Doppler blood flow measurements of the fetal aortic isthmus (AoI) according to whether the sampling plane is obtained from the traditional longitudinal aortic arch (LAA) view or the more recently described three vessels and trachea (3VT) view of the fetal upper mediastinum. METHODS Doppler blood flow measurements of pulsatility index (PI), resistance index (RI), peak systolic (PSV), end-diastolic (EDV) and time-averaged maximum (TAMXV) velocities were performed in the AoI of 40 fetuses between 24 and 36 weeks of gestation. All measurements were sampled in two different sonographic planes of the AoI: the LAA view, at a few millimeters beyond the origin of the left subclavian artery, and the 3VT view, just before the V-shaped junction of the aortic and ductal arches. All scans were performed by the same observer. The reliability of Doppler blood flow measurements was assessed by calculating intraclass correlation coefficients (ICCs) and limits of agreement between the two different sonographic sites evaluating the AoI. RESULTS Mean values of PI, RI, PSV, EDV and TAMXV were similar in the LAA and 3VT views. The PI and vascular velocities were reliably measured from both sonographic sites. ICCs for variability of measurements were 0.78, 0.63, 0.63, 0.60 and 0.55 for PI, RI, PSV, EDV and TAMXV, respectively. Limits of agreement revealed minimal disagreement between the two sites of evaluation of the AoI for all measurements. CONCLUSIONS On the basis of our observations, Doppler blood flow measurements across the fetal AoI can be reliably obtained from both the 3VT and the traditional LAA sonographic views. Since the transverse upper thoracic 3VT plane is achievable in most fetal positions, Doppler study of the AoI appears to be easier than expected.
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Affiliation(s)
- M Del Río
- Department of Obstetrics and Gynecology, ICGON, Hospital Clinic, University of Barcelona, Barcelona, Spain.
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16
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Fouron JC. The unrecognized physiological and clinical significance of the fetal aortic isthmus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 22:441-447. [PMID: 14618654 DOI: 10.1002/uog.911] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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17
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Ruskamp J, Fouron JC, Gosselin J, Raboisson MJ, Infante-Rivard C, Proulx F. Reference values for an index of fetal aortic isthmus blood flow during the second half of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 21:441-444. [PMID: 12768553 DOI: 10.1002/uog.105] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE During fetal life, the parallel position of the two cardiac ventricles confers a special status to the aortic isthmus. Flow through the isthmus reflects the balance between the performances of the two ventricles and their respective peripheral impedances. This study proposes a fetal aortic isthmus flow velocity index and its reference values defined on the basis of gestational age (GA). METHODS Video recordings of 111 normal fetuses from 18 to 39 weeks of gestation were retrospectively reviewed. An isthmus flow velocity index (IFI) was calculated as follows: IFI = (systolic + diastolic)/systolic velocity integrals. GA-specific reference ranges of IFI were constructed. RESULTS An IFI of 1.33 +/- 0.03 was found at 18 weeks. This value decreased slightly but steadily with GA to reach 1.23 +/- 0.16 at 39 weeks. This change is mainly related to a decrease in diastolic velocity integrals. CONCLUSION The proposed IFI provides information on the direction and, indirectly, on the volume of blood flow through the fetal aortic isthmus.
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Affiliation(s)
- J Ruskamp
- Fetal Cardiology Unit, Pediatric Cardiology Service, Department of Pediatrics, Ste-Justine Hospital, University of Montreal, Quebec, Canada
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18
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Jauniaux E, Gulbis B, Burton GJ. The human first trimester gestational sac limits rather than facilitates oxygen transfer to the foetus--a review. Placenta 2003; 24 Suppl A:S86-93. [PMID: 12852418 DOI: 10.1053/plac.2002.0932] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Oxygen (O2) free radicals are a potential teratologic threat to the foetal tissues and are known to be involved in the pathophysiology of common human pregnancy disorders such as miscarriage and pre-eclampsia. During the first two months of human gestation, the placenta surrounds the whole gestational sac, the villi contain only a few capillaries located mainly within the centre of the mesenchymal core, the trophoblastic layer is twice the thickness it will be in the second trimester, the foetal red cells are nucleated and the exocoelomic cavity (ECC) occupies most of the space inside the gestational sac. The ECC contains no oxygen transport system, but anti-oxidant molecules that may provide additional protection to the embryo from oxidative damage are present. Ultrasound and anatomical studies have also demonstrated that the intervillous circulation starts in the periphery of the placenta at around 9 weeks of gestation, and that it becomes continuous and diffuse in the entire placenta only after 12 weeks. Overall, these anatomical features provide indirect evidence that the architecture of the human first trimester gestational sac limits foetal exposure to O2 to what is strictly necessary for its development. These results are in agreement with the concept that the placenta and foetus develop in a physiologically low O2 environment and that its metabolism must be essentially anaerobic. Because of these anatomical arrangements, different nutritional pathways to those operating during most of pregnancy must serve the first-trimester foetus. Up to 9 weeks of gestation, foetal nutrition appears to depend on uterine glandular secretions that are delivered into the intervillous space, supplemented by maternal plasma proteins and other molecules that may percolate through the trophoblastic shell. These molecules diffuse through, or are transported by, the trophoblast of the villi and the chorionic plate into the ECC. From here they are absorbed by the secondary yolk sac (SYS), in which the extraembryonic circulation is probably first established. At the end of the first trimester, the SYS and two-thirds of the placental mass degenerate, and the ECC is progressively obliterated by the enlarging amniotic cavity. The trophoblastic plugs occluding the utero-placental arteries are gradually dislocated, allowing maternal blood to flow into the intervillous space, and the uterine glands involute. These major anatomical transformations modify considerably the spatial relationships between the maternal tissues and the developing embryo, and, consequently, the materno-embryonic exchange pathways. Overall the comparison of morphological features with physiological findings reveals that the architecture of the human first trimester gestational sac is designed to limit foetal exposure to oxygen to that which is strictly necessary for its development, and that during early pregnancy alternative nutritional pathways are in use.
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Affiliation(s)
- E Jauniaux
- Academic Department of Obstetrics and Gynaecology, Royal Free and University College London Medical School, UK.
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19
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Carrera J, Figueras F, Antolín E. Hemodinamia fetal: estudio mediante Doppler. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2003. [DOI: 10.1016/s0210-573x(03)77269-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Bruch JF, Sibony O, Benali K, Challier JC, Blot P, Nessmann C. Computerized microscope morphometry of umbilical vessels from pregnancies with intrauterine growth retardation and abnormal umbilical artery Doppler. Hum Pathol 1997; 28:1139-45. [PMID: 9343320 DOI: 10.1016/s0046-8177(97)90251-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Computerized microscope morphometry was used to study cross sections from the vessels of the umbilical cord in placentas of patients with intrauterine growth retardation (IUGR) that displayed either normal or abnormal umbilical arteries (UA) Doppler flow velocity waveforms (FVW). Cords from 63 eutrophic fetuses with normal Doppler (controls), 47 IUGR fetuses with normal Doppler and 32 IUGR fetuses with abnormal Doppler underwent morphometric analysis using a highly optimized microscope environment (HOME) and "CordHOME" software. IUGR with an accompanying normal Doppler versus control showed a reduction of Wharton jelly and both the total and lumen vein areas. IUGR with an accompanying pathological Doppler showed a comparable reduction in wall thickness and areas of every vessel. These findings indicate that the hypoplastic umbilical vessels are associated with an increase in placental vascular resistance that may be the consequence of underdevelopment in response to a chronic reduction in placental blood flow.
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Affiliation(s)
- J F Bruch
- Laboratoire TIMC-CNRS-IMAG (UMR 5525), Institut Albert Bonniot, La Tronche, France
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21
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Jauniaux E, Jurkovic D, Campbell S. Current topic: in vivo investigation of the placental circulations by Doppler echography. Placenta 1995; 16:323-31. [PMID: 7567794 DOI: 10.1016/0143-4004(95)90089-6] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- E Jauniaux
- Department of Obstetrics and Gynaecology, King's College School of Medicine and Dentistry, University of London, UK
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22
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Abstract
The objective of this review was to find the clinical relevance of the absence of end-diastolic flow velocity in the umbilical artery. Search was conducted through MEDLINE using unabridged MEDLINE Knowledge Finder (Aries System Corp., North Andover, MA). All the manuscripts published in English language within last 10 years (1983-1992) were included in the review process. There has been no report of umbilical artery absent-end diastolic velocity before 1983. It was extremely difficult to draw a conclusion because a majority of the available reports in the literature are either case reports or retrospective analyses. However, for the practical purposes it can be concluded that after viability these pregnancies should be followed by intense (daily) fetal well-being surveillance with conventional antenatal tests. Those who improve their end-diastolic velocity should be allowed to continue the pregnancy as long as antenatal testing is promising. Persistence of absent end-diastolic velocity may be an indication for delivery at a gestational age when there is reasonable chance of survival. Cytogenetic evaluation and anatomical survey of these fetuses by ultrasound is recommended. Long-term follow up of surviving infants needs to be studied. It is impossible for a single institution to accumulate enough cases for adequate outcome evaluation. A randomized prospective trial to assess the management of pregnancies with absent end-diastolic velocity in the umbilical artery would be difficult. Some might even consider such a study unethical. Until such a study is performed, an international registry would be helpful for collecting data about the perinatal outcomes and management of such patients.
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Affiliation(s)
- I Forouzan
- Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia, USA
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23
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Arbeille P, Maulik D, Fignon A, Stale H, Berson M, Bodard S, Locatelli A. Assessment of the fetal PO2 changes by cerebral and umbilical Doppler on lamb fetuses during acute hypoxia. ULTRASOUND IN MEDICINE & BIOLOGY 1995; 21:861-870. [PMID: 7491742 DOI: 10.1016/0301-5629(95)00025-m] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
The objective of the present study was to validate one or a combination of fetal Doppler parameters in order to assess acute fetal hypoxia in an ovine model. Acute hypoxia was induced by reducing umbilical, or maternal aortic flow (approx. 70%). A CW Doppler probe was fixed on the fetal cervical skin, facing the internal carotid artery and the fetal abdominal skin adjacent to the umbilical arteries. (The angle between Doppler beam and flow vector remained constant.) A "Doptek 3000" spectrum analyser was used to measure the maximal and mean Doppler frequencies. Heart rate (HR), umbilical blood flow (UBF), carotid blood flow (CBF), umbilical RI (URI), cerebral RI (CRI) and cerebroplacental ratio (CPR = CRI/URI) were calculated in real time. A catheter was inserted into the fetal femoral artery, for blood gas (PO2, PCO2 pH) and blood pressure (BP) measurements. After 1 min of aorta compression (70% aortic flow reduction), the URI increased by 10% (P < 0.05), and the UBF decreased by 10% (P < 0.05), but the CRI decreased by 20% (P < 0.02), and the CBF did not change significantly. Fetal PO2 and CPR fell down after 1 min (59% and 38%, respectively; P < 0.001), although strong fetal heart rate decelerations were observed. The blood pressure, PCO2 and pH did not change significantly during this test. Throughout the 12 min of cord compression (70% umbilical flow reduction) the URI increased (70% to 80% P < 0.001), and the UBF decreased (approx. 60%; P < 0.001), but the CRI decreased (approx. 25%; P < 0.01), and the CBF remained constant (+/- 5%; ns). Fetal PO2 and CPR all decreased during the compression (30% to 44% and 40% to 60%, respectively; P < 0.001). HR, pH and PCO2 did not change significantly. During cord compression the blood pressure did not change significantly. In both cases, the CPR decreased significantly (P < 0.001) with the PO2 in the same direction and with a comparable amplitude (-30% to -50%). Nevertheless, the drop in CPR was greater during cord compression than during aorta compression, probably because the compression of the cord induced a central hypovolemia in addition to the hypoxia. The CPR was found to be the hemodynamic parameter that followed most closely the PO2 acute changes. The amplitude of the variations of this parameter (-30% to -50%) were quite similar to those of the PO2 during the period of acute hypoxia.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- P Arbeille
- Unité INSERM 316, CHU Trousseau, Tours, France
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24
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Sonesson SE, Fouron JC, Teyssier G, Bonnin P. Doppler echocardiographic assessment of changes in the central circulation of the fetal sheep induced by maternal oxygen administration. Acta Paediatr 1994; 83:1007-11. [PMID: 7841692 DOI: 10.1111/j.1651-2227.1994.tb12972.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Eleven fetal sheep were studied to investigate if Doppler echocardiography could document redistribution of blood flow during maternal oxygen administration. Velocities through the pulmonary valve, aortic valve, common brachiocephalic trunk, aortic arch, descending aorta, umbilical and carotid artery were recorded before, during and after oxygen was delivered to the ewe by face mask. Indices of cardiac performance (shortening fraction, velocity of fiber shortening and systolic time intervals) were also obtained. The aortic arch was the only recording site where significant changes in mean velocity related to oxygen administration and withdrawal were demonstrated (p < 0.01). Changes in the velocity waveform suggesting an increase in cerebral vascular resistance during oxygen administration were found in the carotid artery. Thus, using Doppler velocimetry, the carotid artery and the aortic arch (equivalent to the human aortic isthmus) appear to be suitable sites to document changes induced by maternal oxygen administration.
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Affiliation(s)
- S E Sonesson
- Department of Pediatrics, St Justine Hospital, University of Montreal, Canada
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25
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Gaucherand P, Parisot P, Franck M, Tran Minh V, Rudigoz RC. Velocimetric and biochemical fetal effects of placental embolisation using microspheres in ewes. Eur J Obstet Gynecol Reprod Biol 1994; 53:49-53. [PMID: 8187920 DOI: 10.1016/0028-2243(94)90137-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To investigate the reliability of our animal model and study the fetal response to placental ischemia. STUDY DESIGN Eight monofetal pregnant ewes were fitted with appliances in conformity with a previously defined operating protocol which we have developed. Microspheres at different concentrations were injected through the fetal face of the placenta. The extent of this embolisation was evaluated using biochemical (acid-base balance) and velocimetric criteria (umbilical and carotid arteries). RESULTS Five fetuses received high concentrations of microspheres and developed acute fetal distress (pH = 6.8 +/- 0.05; PO2 = 6.7 +/- 0.4; (S - D)/S (U.A.) = 1.0; (S - D)/S (C.D.) = 0.58 +/- 0.05). Three fetuses received lower concentrations of microspheres and developed chronic fetal distress (pH = 7.2 +/- 0.02; PO2 = 15 +/- 1; (S - D)/S (U.A.) = 0.75 +/- 0.09; (S - D)/S (A.C.) = 0.62 +/- 0.04). CONCLUSION Our experimental model is able to reproduce acute and chronic fetal distress. The concentration of microspheres used to create chronic distress is currently understood. Long-term fetal compensation mechanisms prevent the evaluation of risks linked to each degree of chronic distress in utero. The subsequent aim is to obtain a correlation between velocimetric observations and acid-base balance data.
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Affiliation(s)
- P Gaucherand
- Gynaecological and Obstetric Department, Hopital de la Croix Rousse, Lyon, France
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26
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Eronen M, Kari A, Pesonen E, Kaaja R, Wallgren EI, Hallman M. Value of absent or retrograde end-diastolic flow in fetal aorta and umbilical artery as a predictor of perinatal outcome in pregnancy-induced hypertension. Acta Paediatr 1993; 82:919-24. [PMID: 8111171 DOI: 10.1111/j.1651-2227.1993.tb12600.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
There is insufficient data on the value of absent or retrograde end-diastolic flow (AREDF) in the fetal umbilical artery, descending aorta and aortic arch to predict perinatal outcome. In this prospective investigation, 65 pregnant women between 24 and 34 weeks' gestation with pregnancy-induced hypertension were studied by color Doppler echocardiography. Pregnancies leading to birth at or before 34.0 gestational weeks (23 with and 19 without AREDF) were included in the outcome analysis. Fetuses with AREDF were delivered at earlier gestational ages (p = 0.006). They had a higher incidence of gastrointestinal complications (p = 0.01), bronchopulmonary dysplasia (p = 0.03), intraventricular hemorrhage (p = 0.03) and vascular hypotension (p = 0.03) than those without AREDF. The presence of AREDF was associated with a mortality rate of 30%, whereas in fetuses without AREDF there was no mortality (p = 0.01). Using logistic regression and taking into consideration various perinatal factors, the presence of AREDF (p = 0.03) and early gestational age (p = 0.0001) were associated with serious neonatal diseases or death. A reverse diastolic flow in the aortic isthmus was registered in five fetuses; three died during the perinatal period and one was severely damaged. According to our results, AREDF, particularly with the appearance of reverse diastolic flow in the isthmus of the aortic arch, is a predictor of poor neonatal outcome.
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MESH Headings
- Adult
- Aorta, Thoracic/diagnostic imaging
- Aorta, Thoracic/physiopathology
- Blood Flow Velocity
- Diastole/physiology
- Echocardiography, Doppler
- Female
- Fetal Diseases/diagnostic imaging
- Fetal Diseases/physiopathology
- Humans
- Hypertension/physiopathology
- Infant
- Infant, Newborn
- Infant, Premature, Diseases/diagnostic imaging
- Infant, Premature, Diseases/mortality
- Infant, Premature, Diseases/physiopathology
- Male
- Morbidity
- Predictive Value of Tests
- Pregnancy
- Pregnancy Complications, Cardiovascular/physiopathology
- Pregnancy Outcome
- Prospective Studies
- Regional Blood Flow
- Regression Analysis
- Ultrasonography, Prenatal
- Umbilical Arteries/diagnostic imaging
- Umbilical Arteries/physiopathology
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Affiliation(s)
- M Eronen
- Division of Pediatric Cardiology, Children's Hospital, University Hospital, Helsinki, Finland
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27
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Bonnin P, Fouron JC, Teyssier G, Sonesson SE, Skoll A. Quantitative assessment of circulatory changes in the fetal aortic isthmus during progressive increase of resistance to umbilical blood flow. Circulation 1993; 88:216-22. [PMID: 8319336 DOI: 10.1161/01.cir.88.1.216] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND This study investigated the effects of impairment to placental flow on flow patterns through the aortic isthmus because in the fetus, this vascular segment is the link between the parallel vascular systems perfused by the left and right ventricles. METHODS AND RESULTS A progressive increase in resistance to blood flow through the placenta was created in seven exteriorized fetal lambs by mechanical umbilical vein compression. Blood flows were measured in the ascending aorta, pulmonary artery, aortic isthmus, and umbilical artery at baseline and at each compression level. The severity of the levels of compression was determined by changes in the flow profile through the umbilical artery. An increase in placental resistance causing a fall in umbilical blood flow of approximately 50% was associated with a retrograde diastolic flow through the aortic isthmus even though the diastolic flow through the umbilical artery remained forward. Because of the systolic predominance, however, the net flow in the isthmus was forward. With a more severe increase in placental resistance corresponding to a decrease of 75% in umbilical blood flow, the net flow through the isthmus approached zero. A strong positive correlation was found between the umbilical blood flow and the net flow through the aortic isthmus (r = .89). CONCLUSIONS Variations in Doppler blood flow velocity waveforms and integrals of the aortic isthmus can be used as a sensitive indicator of the state of the umbilical circulation.
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Affiliation(s)
- P Bonnin
- Department of Pediatrics, Saint-Justine Hospital, University of Montreal, Canada
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28
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Di Renzo GC, Luzi G, Cucchia GC, Caserta G, Fusaro P, Perdikaris A, Cosmi EV. The role of Doppler technology in the evaluation of fetal hypoxia. Early Hum Dev 1992; 29:259-67. [PMID: 1396249 DOI: 10.1016/0378-3782(92)90162-a] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Failing intrauterine support to the fetus can lead to intrauterine growth retardation (IUGR) and hypoxia and it is associated with a high risk of perinatal morbidity and mortality. The main effects of moderate to severe hypoxia on the fetus are different degrees of blood flow redistribution and reduction of oxygen consumption to maintain oxygen delivery to the central organs at the expenses of peripheral organs. The redistribution results in a 'brain sparing' effect. Recently, a Doppler ultrasonic technology (continuous wave, pulsed wave and colour flow imaging) has been developed for the non invasive measurement of flow. Doppler velocimetry detects the flow velocity waveform (FVW) which reflects the cardiac output, the vascular compliance and the resistance to the flow in a defined point of the vessel. Velocity waveform indices or even simpler criteria, such as the presence or absence of diastolic flow or flow reverse during diastole, have been applied to a number of fetal vessels. A significant relationship exists between blood oxygen, systemic lactic acidosis (determined by cordocentesis) and increase PI values in umbilical artery (UA), thoracic aorta (TA) and renal artery (RA). Moreover, in experimental animals during steady state hypoxia, several cardiovascular parameters are affected (heart rate/cardiac output decreases and blood pressure increases) while placental flow don't show a significant variation thus suggesting a raise in placental vascular resistance. Redistribution of the flow may be reliably evaluated by the cerebroplacental ratio (i.e. ratio between PI of MCA and PI of UA, c/p).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G C Di Renzo
- Institute of Gynecology and Obstetrics, University of Perugia, Italy
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29
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Abstract
Significant progress has been achieved in regard to normative data for uteroplacental and fetal blood flow velocity and the factors which may affect these observations. Associations have been demonstrated between abnormal indices of maternal and fetal blood flow velocity and pregnancy-induced hypertension, fetal growth retardation, fetal blood gas measures, and intrapartum clinical fetal distress. However, in general, the predictive power is modest and no evidence has yet been provided to indicate that these measures can be used as a screening test in the general obstetric population. Continuing research is highly desirable. At the present time, the use of Doppler assessment of blood flow in pregnancy should be limited to the investigational setting.
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Affiliation(s)
- J A Low
- Department of Obstetrics and Gynecology, Queen's University, Kingston, Ontario, Canada
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