Persistent intrahepatic right umbilical vein: a prenatal sonographic series without significant anomalies

Intrahepatic persistent fetal right umbilical vein: a retrospective study

Introduction: To appraise the incidence and value of intrahepatic persistent right umbilical vein (PRUV).Methods: This was a single-center study. Records of all women with a prenatal diagnosis of intrahepatic PRUV were reviewed. The inclusion criteria were women with gestational age greater than 13 weeks of gestation. Exclusion criteria were fetuses with situs abnormalities, due to the hepatic venous ambiguity, and extrahepatic PRUV. The primary outcome was the incidence of intrahepatic PRUV in our cohort. The secondary outcomes were associated malformations.Results: 219/57,079 cases (0.38%) of intrahepatic PRUV were recorded. The mean gestational age at diagnosis was 21.8 ± 2.9 weeks of gestations. PRUV was isolated in the 76.7%, while in 23.3% was associated with other major or minor abnormalities. The most common associated abnormalities were cardiovascular abnormalities (8.7%), followed by genitourinary abnormalities (6.4%), skeletal abnormalities (4.6%), and central nervous system abnormalities (4.1%). Within the cardiovascular abnormalities, the most common one was ventricular septal defect (six cases).Conclusion: In most cases PRUV is an isolated finding. Associated minor or major malformations are presented in the 23.3% of the cases, so this finding should prompt detailed prenatal assessment of the fetus, with particular regard to cardiovascular system.

Persistent right umbilical vein: a study using serial sections of human embryos and fetuses

Persistent right umbilical vein (PRUV) is a common anomaly of the venous system. Although candidates for future PRUV were expected to occur more frequently in earlier specimens, evaluation of serial horizontal sections from 58 embryos and fetuses of gestational age 5–7 weeks found that only two of these embryos and fetuses were candidates for anomalies. In a specimen, a degenerating right umbilical vein (UV) joined the thick left UV in a narrow peritoneal space between the liver and abdominal cavity, and in the other specimen, a degenerating left UV joined a thick right UV in the abdominal wall near the liver. In these two specimens, the UV drained into the normal, umbilical portion of the left liver. These results strongly suggested that, other than the usual PRUV draining into the right liver, another type of PRUV was likely to consist of the right UV draining into the left liver.

Are congenital malformations more frequent in fetuses with intrahepatic persistent right umbilical vein? A comparative study

OBJECTIVE

Persistent right umbilical vein (PRUV) is a vascular anomaly where the right umbilical vein remains as the only conduit that returns oxygenated blood to the fetus. It has classically been described as associated with numerous defects. We distinguish the intrahepatic variant (better prognosis) and the extrahepatic variant (associated with worse prognosis). The objective of this study was to compare rates of congenital malformations in fetuses with intrahepatic PRUV (I-PRUV) versus singleton pregnancies without risk factors.

MATERIALS AND METHODS

A multicenter, crossover design, comparative study was performed between 2003 and 2013 on fetuses diagnosed with I-PRUV (n=56), and singleton pregnancies without congenital malformation risk factors (n=4050).

RESULTS

Fifty-six cases of I-PRUV were diagnosed (incidence 1:770). A statistically significant association between I-PRUV and the presence of congenital malformations (odds ratio 4.321; 95% confidence interval 2.15-8.69) was found. This positive association was only observed with genitourinary malformations (odds ratio 3.038; 95% confidence interval 1.08-8.56).

CONCLUSION

Our rate of malformations associated with I-PRUV (17.9%) is similar to previously published rates. I-PRUV has shown a significant increase in the rate of associated malformations, although this association has only been found to be statistically significant in the genitourinary system. Noteworthy is the fact that this comparative study has not pointed to a significant increase in the congenital heart malformation rate. Diagnosis of isolated I-PRUV does not carry a worse prognosis.

Perinatal outcome after ultrasound prenatal diagnosis of persistent right umbilical vein

OBJECTIVE

Our aim was to describe ultrasound findings and perinatal outcome after prenatal diagnosis of persistent right umbilical vein (PRUV).

STUDY DESIGN

We performed a retrospective analysis of fetuses with an ultrasound-based prenatal diagnosis of PRUV on record at 2 tertiary centers in Madrid, Spain. We describe clinical, maternal, fetal and perinatal variables for all cases.

RESULTS

A total of 20,426 fetuses were delivered between the study centers. We detected 22 cases (0.1%) of PRUV. The male-to-female ratio was 1:1. All cases were intrahepatic type and diagnosed during the second and third trimesters (median, 21 weeks; IQR, 20-29 weeks). Doppler ultrasound revealed normal flow in the ductus venosus in all cases. Nine fetuses (40.9%) had additional ultrasound anomalies but no chromosomal abnormalities. Cardiovascular malformations were the most frequently associated congenital anomalies (4/9), followed by neurological malformations (2/9). In 5 of the cases with no concomitant anomalies, the weight of the newborn was below the tenth percentile for gestational age. Gestational development was normal for the remaining newborns. Delivery was unremarkable, and post-natal evolution was favorable.

CONCLUSION

Our results point to a potential association between PRUV and other fetal malformations and a very low rate of chromosomal abnormalities. Prenatal diagnosis of PRUV should be followed by detailed anatomical evaluation and echocardiography in order to rule out other structural malformations. The indication for a fetal karyotype study must be made on an individual basis considering PRUV type and other ultrasound findings.

A case of a four-vessel umbilical cord: don’t stop counting at three!

There are various numerical abnormalities of umbilical cord vessels known in the literature, the single umbilical artery being the most prevalent. A four-vessel umbilical cord is found less frequently, and moreover, is less well-known in daily practice. A persistent right umbilical vein, however, can be associated with potentially serious congenital defects. A case of a four-vessel umbilical cord containing two arteries and two veins is presented. The literature on this subject reports both a differentiation between the two variants, intrahepatic and extrahepatic, which can be distinguished during antenatal ultrasound screening, and a possible association with congenital abnormalities, some of which can carry substantial morbidity and mortality. Although the incidence of a four-vessel umbilical cord is low, its presence should be considered both during routine antenatal ultrasound screening and on physical examination of any neonate.

Persistent right umbilical vein: a prenatal condition worth mentioning?

OBJECTIVES

To investigate the incidence and clinical impact of prenatally diagnosed persistent right umbilical vein (PRUV) in a referral population and to evaluate the findings together with those from previous publications.

METHODS

This was a retrospective analysis of 39 cases with PRUV diagnosed in three tertiary referral centers for prenatal medicine between 1996 and 2009. Fetuses with situs inversus, situs ambiguous and heterotaxy (left and right isomerism) were excluded. During the study period 46 653 consecutive high- and low-risk pregnancies were examined. The prenatal sonograms and neonatal outcome data of affected individuals were reviewed. Our findings were analyzed together with findings retrieved from the scientific literature.

RESULTS

Twenty-nine fetuses had an isolated PRUV as a single anomaly, whereas 10/39 (25.6%) were found to have PRUV accompanied by additional minor and major abnormalities. These anomalies comprised mainly cardiovascular, genitourinary and gastrointestinal malformations. In common with our series, previously published cases of isolated PRUV (n = 197) displayed an uneventful course of pregnancy and a favorable postnatal outcome. Sixty-six previously reported cases of PRUV with additional anomalies were identified in the literature. Intrahepatic umbilical drainage is the most frequent type of PRUV. Including our cases, there were 16 cases (5.3%) with extrahepatic drainage of PRUV, all of which had additional anomalies.

CONCLUSIONS

Consistent with previous reports, in the majority of cases (74.8%) PRUV is an isolated finding. While these cases carry an excellent prognosis, PRUV can be associated with severe congenital anomalies, so this finding should prompt detailed prenatal assessment of the fetus.

Successful mesenterico-left portal vein bypass in a child with duplicated round ligaments and rex recessi

A 3-year-old girl with idiopathic extrahepatic portal vein obstruction undergoing mesenterico-left portal vein bypass (MLPVB), or Rex shunt, for recurrent variceal bleeding was intraoperatively discovered to have duplicated round ligaments and Rex recessi. The left and right portal veins connected to their respective round ligaments but had minimal communication within the liver. Intraoperative venography identified a better preserved portal system on the left, and standard MLPVB resulted in excellent shunt flow. The shunt remains patent and the patient asymptomatic 9 months after her operation. Abnormal portal anatomy is not a contraindication to MLPVB.

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

The human fetal venous system is well-recognized as a target for investigation in cases of circulatory compromise, and a broad spectrum of malformations affecting this system has been described. In Part I of this review, we described the normal embryology, anatomy and physiology of this system, essential to the understanding of structural anomalies and the sequential changes encountered in intrauterine growth restriction and other developmental disorders. In Part II we review the etiology and sonographic appearance of malformations of the human fetal venous system, discuss the pathophysiology of the system and describe venous Doppler investigation in the fetus with circulatory compromise.

Right ligamentum teres joining to the right branch of the portal vein

Ligamentum teres joining to the right branch of the portal vein in a 79-year-old Japanese male cadaver was noted during student dissection at Kumamoto University in 2004. The ligamentum teres entered the liver along the left side of the gallbladder fossa. The quadrate lobe was not distinguished from the left lobe in the visceral surface. When the liver parenchyma was removed by tearing off to expose the branches of the portal and hepatic veins, it was clarified that the ligamentum teres unusually joined to the bifurcation of the upper anterior and lower anterior branches of the right branch of the portal vein. The ligamentum teres is the remnant of the umbilical vein working throughout fetal life. Initially a pair of the umbilical veins entered the sinus venosus. During the fourth and fifth weeks they connect to the hepatic sinusoids, which become the portal and hepatic veins, and the parts entering the sinus venosus of both umbilical veins disappear. By the eighth week, as all remainder of the right umbilical vein disappears, the left umbilical vein is the only one to carry blood from the placenta to the liver. It results in the ligamentum teres joining to the left branch of the portal vein. However, in the present case it is thought that the right umbilical vein remained instead of the left one for some reason, and it then became the right ligamentum teres joining to the right branch of the portal vein.

Persistent Right Umbilical Vein and Left-Sided Gallbladder

Three cases of persistent right umbilical vein associated with left-sided gallbladder are presented. This poorly understood, rare variant is due to obliteration of the left umbilical vein during embryonic development. The left-sided gallbladder, associated with persistent right umbilical vein, is not anomalous positioning of the gallbladder but an embryologic abnormality of the umbilical vein that causes the gallbladder to migrate to the left of the ligament teres. Findings and clinical relevance are discussed.

Prenatal diagnosis of persistent right umbilical vein using three-dimensional sonography with power Doppler

OBJECTIVE

To investigate the incidence and the importance of isolated persistent right umbilical vein (PRUV) in our obstetric population and to determine the role of three-dimensional (3D) ultrasound in prenatal diagnosis of isolated PRUV.

MATERIAL AND METHODS

A total of 1,302 women who received regular antenatal care by a sole obstetrician at our hospital were prospectively evaluated between July 2003 and April 2005. Detailed anatomical evaluation of the fetus was performed by one sonographer. When the diagnosis of PRUV was made, it was confirmed by a senior obstetrician. 3D ultrasound with power Doppler was applied to delineate local anatomy. Echocardiography was performed in all the newborns by pediatric cardiologists to confirm the prenatal diagnosis and to evaluate for the presence of associated anomalies.

RESULTS

Six fetuses with PRUV were detected among the 1,302 study subjects. The incidence of PRUV in our population was 0.46% (1:217 live births). Vascular anatomy was easy to demonstrate using 3D power Doppler. The ductus venous (DV) was present in all six fetuses. An atrial septal defect was shown to exist in four newborns by neonatal echocardiography, but spontaneous closure had occurred in the follow-up scan.

CONCLUSION

PRUV is a common vascular anomaly that is easy to be overlooked. Reconstruction of the portal system in the affected fetuses using 3D ultrasound facilitated the identification of the DV. If the DV is present, and other anomalies are excluded, the fetus with PRUV has a good outcome.

Prenatal diagnosis of umbilicoportosystemic shunts: report of 11 cases and review of the literature

OBJECTIVE

The objective of our study was to classify, understand, and illustrate abnormalities of the embryologic development of the umbilical vein and the portal system resulting in umbilicoportosystemic shunts. According to our data and a review of the literature, we propose an anatomic, biometric, and hemodynamic assessment of umbilicoportosystemic shunts.

CONCLUSION

Umbilicoportosystemic shunts encompass different congenital vascular abnormalities that should be recognized because they may interfere with fetal growth and circulation.

Abnormal systemic venous connection possibly associated with a persistent right umbilical vein; a case report

Background

Abnormal venous connections involving a persistent right umbilical vein are rare. In a minority of cases the liver is entirely bypassed and the condition is associated with multiple congenital malformations.

Case presentation

The described case illustrates a systemic venous drainage that was severely abnormal in a newborn girl with a truncus arteriosus type II congenital heart defect. Injection of contrast medium through the umbilical vein catheter revealed a very peculiar venous connection that passed anterio-laterally through the right hemithorax before crossing in an oblique fashion towards the superior vena cava.

Conclusions

This venous drainage may be the result of a persistent right umbilical vein connecting with the superior vena cava.

The human fetal venous system: normal embryologic, anatomic, and physiologic characteristics and developmental abnormalities

OBJECTIVE

The introduction of high-resolution ultrasonography combined with color-coded Doppler imaging offered a breakthrough in the evaluation of the human fetal venous system, considerably enhancing our understanding of fetal venous circulation in normal physiologic conditions, as well as providing us the ability to study circulatory changes in abnormal circumstances. The purpose of this study was to describe the normal anatomic development and complex of anomalies of the human fetal venous system and to review recently published series of these anomalies.

METHODS

Normal embryologic and anatomic development is described. An English language literature search of recent MEDLINE listings was performed to glean data from recently published series reporting prenatal diagnosis of the various anomalies and their associated malformations.

RESULTS

Anomalies of the human fetal venous system occur sporadically, often associated with cardiac or other malformations. The pathophysiologic mechanisms leading to abnormal in utero development of the human venous system remain largely undetermined. On the basis of the type of vein involved, embryologic precursor, and etiologic correlation (primary or secondary), classification into 4 major groups is described.

CONCLUSIONS

Prenatal evaluation of fetuses found to have anomalies of the venous system should include a careful search for cardiac anomalies, including pulmonary venous drainage, and a detailed anatomic survey of the umbilical, portal, hepatic, and ductal systems to determine aberrant communication and, if possible, to discover clues to systemic diseases or thromboembolic phenomena.

Persistent right umbilical vein: incidence and significance

OBJECTIVES

To conduct a prospective evaluation of the incidence and neonatal outcome of fetuses with persistent right umbilical vein. This condition had traditionally been considered to be extremely rare and to be associated with a very poor neonatal prognosis, but later evidence has raised some doubts about the veracity of these contentions.

METHODS

Between August 1995 and November 1998, 8950 low-risk patients were prospectively evaluated at two medical centers. The sonographic diagnosis of a persistent right umbilical vein was made in a transverse section of the fetal abdomen when the portal vein was curved toward the stomach, and the fetal gall bladder was located medially to the umbilical vein.

RESULTS

Persistent right umbilical vein was detected in 17 fetuses during the study. Four of them had additional malformations, of which three had been detected antenatally.

CONCLUSIONS

We established that the incidence of persistent right umbilical vein in a low-risk population is 1 : 526. We believe that the sonographic finding of this anomaly is an indication for conducting targeted fetal sonography and echocardiography. When the persistent right umbilical vein is connected to the portal system and other anomalies are ruled out, the prognosis can generally be expected to be favorable.

Abnormalities of the fetal central veins and umbilico-portal system: prenatal ultrasonographic diagnosis and proposed classification

OBJECTIVES

Anomalies of the fetal venous system are poorly documented and their pathogenesis is not well understood. The present study was undertaken to review the spectrum of fetal central veins and umbilico-portal system anomalies, and to propose a classification system.

METHODS

A 7-year restrospective survey was conducted.

RESULTS

Nineteen fetuses showed abnormal connection between central veins and the fetal heart. Three fetuses showed abnormal connections of the cardinal veins, two of which had interruption of the inferior vena cava, and one had isolated persistent left superior vena cava. Anomalies of pulmonary veins were seen in four fetuses: in two with asplenia syndrome, a vertical confluent pulmonary artery was observed. In a further two cases total anomalous pulmonary venous connections were found. Abnormalities of the umbilical vein (UV) were seen in 10 cases; seven had persistent right UV, and three had a spectrum of anomalies: One had abnormal connections of the UV to the left iliac vein associated with agenesis of the ductus venosus (DV) and hydrops fetalis. One case showed in utero occlusion of the DV by echogenic foci that resulted in a persistent left proximal UV and porto-systemic shunt. One case had obliteration of the DV secondary to in utero fetal hepatic fibrosis. Abnormalities of the vitelline veins or portal system were demonstrated in two cases. One had a left porto-systemic shunt which resolved spontaneously at 3 months of age, and one had secondary partial occlusion of the left portal system with liver echogenicities and direct communication of the UV with the right atrium. None of the 19 cases had an abnormal karyotype or evidence of in utero infection.

CONCLUSIONS

Detection of various fetal vein anomalies in utero is feasible. The anomalies vary according to embryologic precursors or etiology. Two major mechanisms seem to be involved in the genesis of fetal vein anomalies: in most cases primary maldevelopment of the venous system occurs, while in the minority secondary anomalies from possible thromboembolic events or systemic disease may play a role.

Prenatal sonographic diagnosis of persistent right umbilical vein with varix

Persistence of the right umbilical vein is variably associated with life-threatening malformations of the fetal genitourinary, gastrointestinal, cardiac, and skeletal systems. Varices of the intraabdominal umbilical vein, although not necessarily associated with other malformations, do seem to carry a risk of fetal mortality, especially if they are large or appear early during the pregnancy. We report the prenatal diagnosis of the rare combination of persistence and varix of the right umbilical vein in an otherwise healthy infant.