Prenatal sonographic diagnosis of intrahepatic portosystemic shunts

Prenatal sonographic characteristics and postnatal outcomes of congenital portosystemic shunt diagnosed during the fetal period: a systematic review

BACKGROUND

Congenital portosystemic shunt (CPSS) is a rare vascular malformation which results in anomalous communication between the portal venous system and the systemic vein. The objective of this review is to describe the prenatal ultrasonic characteristics and postnatal outcomes of CPSS diagnosed prenatally, along with providing some suggestions for perinatal monitoring.

MATERIALS AND METHODS

A systematic literature search was conducted in PubMed and Ovid electronic databases in a period from January 2012 to May 2024, using the terms: "congenital portosystemic shunt", "ductus venosus", "Abernethy malformation" and "umbilical-portal-systemic venous shunt". All original studies reporting CPSS patients diagnosed prenatally were included. Studies published in languages other than English or studies that did not report the clinical information of patients were excluded. Two reviewers independently screened articles for inclusion and extracted data.

RESULTS

A total of 39 studies which included 525 cases were enrolled in the systematic review. Among the included patients, 49 (9%) had umbilical-systemic shunt (USS), 264 (50%) had ductus venosus-systemic shunt (DVSS), 159 (30%) had intrahepatic portal-systemic shunt (IHPSS), 32 (6%) had extrahepatic portal-systemic shunt (EHPSS) and 9 (2%) had mixed shunts which meant that they had more than one type of shunts. There were also 12(3%) patients were excluded because the specific type was not described in the study. CPSS patients could have severe comorbidities such as chromosomal aberrations and cardiovascular malformations. Compared with other groups, fetuses with IHPSS had the lowest incidence of severe comorbidities. Most patients received conservative treatment while interventional and surgical treatments were used for some patients.

CONCLUSION

We suggest that fetuses diagnosed with CPSS should be treated differently according to their types and clinical manifestations. IHPSS patients are more likely to have good outcomes so they may benefit from the "wait-and-see" approach while the other groups deserve closer monitoring. Personalized treatment is essential as CPSS patients can be asymptomatic or have severe complications.

Prenatal Ultrasound Diagnosis of Fetal Type IV Intrahepatic Portosystemic Shunt: A Rare Case Report

Fetal intrahepatic portosystemic shunt (IPSS) is a rare vascular anomaly that poses significant postnatal risks. Paul et al. classified congenital IPSS into four types: (I) a single large tube connecting the right portal vein to the inferior vena cava; (II) a localized peripheral shunt with communications in one hepatic segment; (III) an aneurysmal shunt; (IV) multiple diffuse communications in both lobes. We report a unique case of Type IV IPSS diagnosed at 29 weeks of gestation using prenatal ultrasound and Doppler imaging. The shunt was characterized by tortuous portal vein branches draining into hepatic veins, accompanied by fetal growth restriction and mild tricuspid regurgitation. This case highlights the value of detailed prenatal imaging for accurate diagnosis, classification, and perinatal planning. Early identification and close monitoring of fetal IPSS can optimize neonatal outcomes and guide postnatal interventions.

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.

Congenital intra-hepatic porto-systemic shunts diagnosed during intrauterine life: Systematic review

OBJECTIVE

To describe the ultrasonographic characteristics of congenital porto-systemic venous shunts (CPSS) diagnosed during pregnancy, their outcomes, and their evolution.

METHODS

Two independent researchers selected 493 review articles and case reports through the analysis of titles, abstracts, and full text. The PubMed and LILACS databases were searched. Through the application of filters according to the PRISMA protocol, only six articles were used in the research. The following information was collected, when available: gestational age at diagnosis, gender, birth weight, type of shunt, associated anomalies/complications and treatment/progression.

RESULTS

The data were obtained from 27 cases, with 22 (82%) fetuses diagnosed with intra-hepatic CPSS and 5 (18%) with extra-hepatic CPSS. The median time of intrauterine diagnosis was 33 weeks. In 12 (57.1%) of the 21 pregnancies evaluated, delivery was preterm. The estimated fetal weight ranged from 1150 to 3760 g, with 4 (25%) cases at <3rd, 3 (18.75%) cases at <10th, 8 (50%) cases at <50th, and 1 (6.25%) case at >97th percentile for gestational age. The most frequent obstetric complication was fetal growth restriction, which occurred in nine (60%) cases. As for postnatal treatment, 19 (70.4%) cases were conservatively treated, and 8 (29.6%) cases required surgical intervention.

CONCLUSION

The diagnosis of CPSS still represents a challenge during prenatal care. Its early identification aims to provide guidance to pregnant women and their families, as well as follow-up and anticipation of possible complications, in addition to the evaluation of the mode of delivery and postnatal follow-up, directing the short- and long-term prognosis.

Fetal Intrahepatic Umbilical-Porto-Systemic Venous Shunts (IHUPSVS): in-utero anatomic classification

OBJECTIVE

Congenital intrahepatic shunts divert highly oxygen and nutrients rich placental blood flow from the liver into the systemic flow having a negative influence on normal fetal growth and postnatal development. The ability to recognize this anomaly helps assess the possible clinical impact, counseling, and management of pregnancy. The present study aimed to propose in utero classification for the Intrahepatic Umbilical-Porto-Systemic Venous Shunt (IHUPSVS) based on our experience.

STUDY DESIGN

A prospective study. Grayscale ultrasound with two and three-dimensional high-definition Doppler modalities was used. IHUPSVS was defined as a diversion of blood from the liver tissue by abnormal communication between a branch of the intrahepatic Umbilical vein or the Portal veins with the systemic circulation (the Hepatic veins or the Sub-Diaphragmatic Vestibulum).

RESULTS

Twenty-five fetuses were diagnosed with IHUPSVS. We identified three main anatomic types: I) Porto-hepatic shunt which was divided into Ia) regular single shunt (15/25, 60%) and Ib) regular multiple shunts, (6/25, 24%) II) Umbilical-Porto-Hepatic shunt divided into a) Umbilical or b) Umbilical combined with Portal hepatic shunt (2/25, 8%) and III) Cavernous- aneurysmatic shunt (2/25, 8%). All the shunts were verified by postnatal targeted sonography.

CONCLUSIONS

This study creates the anatomic basis for common nomenclature and future probable updating for this anomaly.

Prenatal 3D-ultrasound diagnosis of isolated intrahepatic portal-systemic shunt with intact ductus venosus: A case report and literature review

We present a case of isolated intrahepatic portosystemic shunts with an aorto- hepatic-umbilical connection; prenatally diagnosed with 3D Doppler flow in a 27-year-old patient at 27 weeks of gestation. Fetal karyotyping was normal, detailed evaluation of the venous and cardiovascular system showed a patent ductus venosus and no other abnormalities. These fetuses with isolated intrahepatic shunts are at risk for intra-uterine growth restriction (27%), all cases had a good prognosis with live births. Postnatal follow-up to control shunt closure is vital as persistent shunts may lead to subsequent complications.

The intra-hepatic umbilical-Porto-systemic venous shunt and fetal growth

OBJECTIVE

The fetal liver circulation has an important role in fetal growth. The intra-hepatic Umbilical-Porto-Systemic Venous Shunt (IHUPSVS) causes a reduction of the umbilical blood flow to the liver and has been reported to have a restrictive effect on fetal growth. The aim of this study was to evaluate the effect of IHUPSVS on fetal growth.

METHODS

We conducted a retrospective cohort study of IHUPSVS diagnosed between 2001 and 2019. IHUPSVS was defined as any abnormal communication between any branch of the portal vein and hepatic vein. Pre- and postnatal characteristics were collected from medical files and compared between cases with fetal growth restriction (FGR) and those appropriate for gestational age (AGA).

RESULTS

Twenty-five fetuses were included in the study. Eighteen (72%) had last estimated fetal weight and birth weight below the 10th centile, four (16%) of them between the third and fifth centile, and 11 (44%) below the third centile. Median gestational age at delivery was lower for FGR than AGA fetuses (37 vs. 38 weeks, p = 0.034) and rate of preterm delivery was higher (38.9 vs. 14.3, P = 0.24). Four cases had associated structural anomalies (2 in each group), and two had minor genetic aberrations (1 in each group).

CONCLUSIONS

Growth restriction is prevalent in fetuses with IHUPSVS, suggesting that fetal growth should be monitored. In equal measure, in cases with growth restriction, especially without other apparent cause, an intrahepatic shunt should be looked for.