B-flow/spatiotemporal image correlation M-mode: novel ultrasound method that detects decrease in spiral artery luminal diameter in first trimester in primate model of impaired spiral artery remodeling.

OBJECTIVE: To determine if B-flow/spatiotemporal image correlation (STIC) M-mode ultrasonography detects a decrease in spiral artery luminal diameter and volume flow during the first trimester in a non-human primate model of impaired spiral artery remodeling (SAR). METHODS: Pregnant baboons were treated daily with estradiol benzoate on days 25-59 of the first trimester (term, 184 days), or remained untreated. On day 60 of gestation, spiral artery luminal diameter (in seven untreated and 12 estradiol-treated baboons) and volume flow (in four untreated and eight estradiol-treated baboons) were quantified by B-flow/STIC M-mode ultrasonography. In addition, in 15 untreated and 18 estradiol-treated baboons, the percent of spiral arteries remodeled by extravillous trophoblasts was quantified ex vivo by immunohistochemical image analysis on placental basal plate tissue collected via Cesarean section on day 60. Findings were compared between treated and untreated animals. The correlation between spiral artery luminal diameter and percent of SAR was assessed in three untreated and six estradiol-treated baboons which underwent both B-flow/STIC M-mode ultrasound and quantification of SAR. RESULTS: The proportion of spiral arteries greater than 50 µm in diameter remodeled by extravillous trophoblasts was 70% lower in estradiol-treated baboons than in untreated animals (P = 0.000001). Spiral artery luminal diameter in systole and diastole, as quantified by B-flow/STIC M-mode in the first trimester of pregnancy, was 31% (P = 0.014) and 50% (P = 0.005) lower, respectively, and volume flow was 85% lower (P = 0.014), in SAR-suppressed baboons compared with untreated animals. There was a significant correlation between spiral artery luminal diameter as quantified by B-flow/STIC M-mode ultrasonography and the percent of SAR (P < 0.05). CONCLUSION: B-flow/STIC M-mode ultrasonography provides a novel real-time non-invasive method to detect a decrease in uterine spiral artery luminal diameter and volume flow during the cardiac cycle, reflecting decreased distensibility of the vessel wall, in the first trimester in a non-human primate model of defective SAR. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

First-trimester fetal cardiac examination using spatiotemporal image correlation, tomographic ultrasound and color Doppler imaging for the diagnosis of complex congenital heart disease in high-risk patients.

OBJECTIVE: A four-dimensional (4D) fetal echocardiographic technique utilizing spatiotemporal image correlation, tomographic ultrasound imaging display (STIC-TUI echo) and color Doppler has previously been shown to be effective in displaying the examination planes constituting the extended cardiac examination. The aim of this study was to evaluate the performance of this first-trimester STIC-TUI echo technique in identifying complex congenital heart disease (CHD) in high-risk pregnancies. METHODS: This was a prospective study of patients presenting at first-trimester screening who were at high risk for CHD owing to pregestational diabetes, in-vitro fertilization (IVF), increased nuchal translucency (NT) thickness, first-trimester tricuspid regurgitation or reversed ductus venosus (DV) a-wave, a previous child with CHD or who were on anticonvulsant medication. First-trimester STIC-TUI echo was performed, and the findings were correlated with second-trimester echocardiography and post-delivery echo findings in survivors. RESULTS: One hundred and sixty-four fetuses from 152 patients were enrolled (77 diabetics, 38 IVF, 14 with increased NT, 23 cases of tricuspid regurgitation or reversed a-wave in the DV, 22 with prior CHD and two on anticonvulsants). STIC-TUI echo was abnormal in 20 (12%), showing atrioventricular canal defect (n = 9), hypoplastic left heart (n = 2), pulmonary stenosis (n = 2), right aortic arch (n = 1), interrupted aortic arch (n = 1), tricuspid atresia (n = 1), heterotaxy (n = 1), persistent truncus arteriosus (n = 1), double outlet right ventricle and ventricular septal defect (n = 1) and double inlet ventricle with transposition of the great arteries (n = 1). 85% of these anomalies were evident in the four-chamber view plane of the TUI display, and the remainder were diagnosed in the outflow tract planes with color Doppler imaging. In 13, CHD was isolated while seven had extracardiac anomalies. Thirteen fetuses had aneuploidy and all 13 underwent first-trimester termination of pregnancy. In the remaining seven, second-trimester echocardiography and neonatal echo/postmortem examination confirmed anomalies (two stillborn neonates, one neonatal death, four live births). Two cases of CHD missed by first-trimester STIC-TUI echo were diagnosed on second-trimester echo. Accordingly, first-trimester STIC-TUI echo had 91% sensitivity and 100% specificity for the detection of CHD. CONCLUSIONS: First-trimester 4D echocardiography using a standardized application of STIC, TUI and color Doppler imaging is effective in displaying the imaging planes that are necessary for achieving the diagnosis of complex cardiac anomalies in high-risk patients. Optimal imaging of the four-chamber view with two-dimensional ultrasound is the major determinant of successful volume acquisition.

Hematologic profile of neonates with growth restriction is associated with rate and degree of prenatal Doppler deterioration.

OBJECTIVE: To examine the relationship between hematologic parameters at birth and prenatal progression of Doppler abnormalities in fetal growth restriction (FGR). METHODS: The study was a secondary analysis of FGR patients (abdominal circumference < 5th percentile and umbilical artery pulsatility index (UA-PI) elevation) with at least three examinations prior to delivery. Prenatal progression was classified as rapid, moderate or slow based on the interval between diagnosis and delivery and the extent of UA, middle cerebral artery and ductus venosus Doppler abnormalities. Associations between diagnosis-to-delivery interval, Doppler Z-scores, progression and hematologic parameters at birth were examined. RESULTS: Of 130 patients, 54 (41.5%) had rapid, 51 (39.2%) moderate and 25 (19.2%) slow deterioration, delivering within 4, 6 and 9 weeks of diagnosis, respectively. The strongest association of moderate and rapid deterioration was with a low platelet count (r2 = 0.37 and 0.70, respectively; P < 0.0001). In patients with moderate deterioration, platelet count correlated inversely with UA-PI (ρ = -0.44, P = 0.001) and was lowest when end-diastolic velocity was absent. With rapid progression, platelet count correlated inversely with nucleated red blood cell count (ρ = -0.51, P < 0.001) but no longer with UA-PI. CONCLUSION: Our observations suggest a relationship between prenatal clinical progression of FGR and hematologic abnormalities at birth. Accelerating cardiovascular deterioration is associated with decreased platelet count, which can be explained by placental consumption or dysfunctional erythropoiesis and thrombopoiesis.

When are amniotic fluid viral PCR studies indicated in prenatal diagnosis?

OBJECTIVE: To determine which prenatal ultrasound findings indicate the need to also obtain PCR studies for viral genome in women undergoing midtrimester amniocentesis. METHODS: This was a retrospective observational study on women that underwent amniotic fluid karyotyping and viral PCR testing for history or ultrasound based indication. Amniotic fluid was tested for adenovirus, cytomegalovirus, respiratory syncytial virus, enterovirus, Epstein-Barr virus, and parvovirus B19 using multiplex PCR study with multiple appropriate controls. Ultrasound findings were coded as normal or abnormal with 34 categories of ultrasound abnormality stratified into 18 subgroups. Relationships between these subgroups and karyotype/PCR results were tested by Pearson chi-square method or Fisher's exact test and overall logistic regression analysis. RESULTS: Amniotic fluid samples from 1191 patients were obtained for the study. Abnormal karyotype was detected in 5.4% of cases (64/1191), and PCR was positive in 6.5% of cases (77/1191). Abnormal fetal ultrasonographic findings were observed in 28.4% of cases (338/1191). There was an association between intrauterine growth restriction, nonimmune hydrops fetalis, hand/foot anomalies or neural tube defects (NTDs), and PCR positivity. NTDs were associated with PCR positivity in fetuses with normal karyotype and nuchal thickening, cardiac or ventral wall defects were specifically associated with aneuploidy. CONCLUSION: Amniotic fluid viral PCR testing should be considered for fetuses with intrauterine growth restriction, nonimmune hydrops fetalis, hand/foot anomalies, or NTDs. After aneuploidy is excluded, NTDs are associated with PCR positivity.

Duration of persistent abnormal ductus venosus flow and its impact on perinatal outcome in fetal growth restriction.

OBJECTIVE: To study if the duration of individual Doppler abnormalities is an independent predictor of adverse outcome in fetal growth restriction (FGR) caused by placental dysfunction. METHODS: This was a secondary analysis of patients with FGR (abdominal circumference < 5(th) percentile and umbilical artery (UA) pulsatility index (PI) elevation) who had at least three examinations before delivery. Days of duration of absent/reversed UA end-diastolic velocity (UA-AREDV), low middle cerebral artery PI (brain sparing), ductus venosus (DV) and umbilical vein Doppler abnormalities were related to stillbirth, major neonatal morbidity and intact survival. RESULTS: One hundred and seventy-seven study participants underwent a total of 1069 examinations. The duration of an absent/reversed a-wave in the DV (DV-RAV) was significantly higher in stillbirths (median, 6 days) compared with intact survivors and those with major morbidity (median, 0 days for both; P = 0.006 and P = 0.001, respectively). Duration of brain sparing was also longer in stillbirth cases compared with intact survivors (median, 19 days vs. 9 days, P = 0.02). Stepwise multinomial logistic regression showed that gestational age at delivery was a significant codeterminant of outcome for all arterial Doppler abnormalities when the DV a-wave was antegrade. However, when present, the duration of DV-RAV was the only contributor to stillbirth (probability of stillbirth = 1/(1 + exp - (interval to delivery × 1.03 - 2.28)), r2 = 0.73). Receiver-operating characteristics curve statistics showed that a DV-RAV for > 7 days predicted stillbirth (100% sensitivity, 80% specificity, likelihood ratio = 5.0, P < 0.0001). In contrast, neither neonatal death nor neonatal morbidity was predicted by the days of persistent DV-RAV. CONCLUSIONS: The duration of absent or reversed flow during atrial systole in the DV is a strong predictor of stillbirth that is independent of gestational age. While prematurity remains the strongest predictor of neonatal risks it is unlikely that pregnancy can be prolonged by more than 1 week in this setting.

Standardization of the first-trimester fetal cardiac examination using spatiotemporal image correlation with tomographic ultrasound and color Doppler imaging.

OBJECTIVE: The challenges of the first-trimester examination of the fetal heart may in part be overcome by technical advances in three-dimensional (3D) ultrasound techniques. Our aim was to standardize the first-trimester 3D imaging approach to the cardiac examination to provide the most consistent and accurate display of anatomy. METHODS: Low-risk women with normal findings on first-trimester screening at 11 to 13 + 6 weeks had cardiac ultrasound using the following sequence: (1) identification of the four-chamber view; (2) four-dimensional (4D) volume acquisition with spatiotemporal image correlation (STIC) and color Doppler imaging (angle = 20 degrees, sweep 10 s); (3) offline, tomographic ultrasound imaging (TUI) analysis with standardized starting plane (four-chamber view), slice number and thickness; (4) assessment of fetal cardiac anatomy (four-chamber view, cardiac axis, size and symmetry, atrioventricular valves, great arteries and descending aorta) with and without color Doppler. RESULTS: 107 consecutive women (age, 16-42 years, body mass index 17.2-50.2 kg/m(2)) were studied. A minimum of three 3D volumes were obtained for each patient, transabdominally in 91.6%. Fetal motion artifact required acquisition of more than three volumes in 20%. The median time for TUI offline analysis was 100 (range, 60-240) s. Individual anatomic landmarks were identified in 89.7-99.1%. Visualization of all structures in one panel was observed in 91 patients (85%). CONCLUSION: Starting from a simple two-dimensional cardiac landmark-the four-chamber view-the standardized STIC-TUI technique enables detailed segmental cardiac evaluation of the normal fetal heart in the first trimester.

Progression of Doppler abnormalities in intrauterine growth restriction.

OBJECTIVE: To identify the sequence of progression of arterial and venous Doppler abnormalities from the onset of placental insufficiency in intrauterine growth restriction (IUGR). METHODS: Prospective observational study of singletons with IUGR (abdominal circumference < 5(th) percentile) who underwent serial standardized umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and umbilical vein (UV) Doppler surveillance. Time intervals between progressive Doppler abnormalities and patterns of deterioration were related to UA Doppler status and gestational age. RESULTS: Six hundred and sixty-eight longitudinal examinations were performed in 104 fetuses, identifying three patterns of progression: (1) Mild placental dysfunction (n = 34) that remained confined to the UA/MCA. The UA became abnormal at a median of 32 weeks' gestation but the pulsatility index never exceeded 3 SD above normal. Progression took a median of 33 days, requiring delivery at a median of 35 weeks. (2) Progressive placental dysfunction (n = 49). Initially normal UA Doppler PI at 29 weeks' gestation increased beyond 3 SD, progressing to abnormal MCA, absent/reversed UA diastolic flow, abnormal DV, UV pulsations in 9-day intervals requiring delivery by 33 weeks. (3) Severe early-onset placental dysfunction (n = 21). Markedly elevated UA PI established by 27 weeks' gestation was associated with rapid (7-day intervals) progression to abnormal venous Doppler with median delivery at 30.6 weeks. Gestational age at onset, time to delivery and progression intervals were different between patterns (all P < 0.05). CONCLUSION: The characteristics of cardiovascular manifestations in IUGR are determined by the gestational age at onset and the severity of placental disease. Recognition of these factors is critical for planning fetal surveillance in IUGR.

Doppler and biophysical assessment in growth restricted fetuses: distribution of test results.

OBJECTIVE: Multi-vessel Doppler ultrasonography and biophysical profile scoring (BPS) are used in the surveillance of growth restricted fetuses (IUGR). The interpretation of both tests performed concurrently may be complex. This study examines the relationship between Doppler ultrasonography and biophysical test results in IUGR fetuses. METHODS: Three hundred and twenty-eight IUGR fetuses (abdominal circumference < 5th percentile, elevated umbilical artery (UA) pulsatility index (PI)) had concurrent surveillance with UA, middle cerebral artery (MCA) and ductus venosus (DV) Doppler ultrasonography and BPS (fetal tone, movement, breathing, maximal amniotic fluid pocket and fetal heart rate). Patients were stratified into three groups according to their Doppler examination: (1) abnormal UA alone; (2) brain sparing (MCA-PI > 2 SD below mean for gestational age); and (3) abnormal DV (PI > 2 SD above the mean for gestational age) and BPS groups: (1) normal (> 6/10); (2) equivocal (6/10); and (3) abnormal (< 6/10). Predictions of short-term perinatal outcomes by both modalities were compared for stratification. The distribution and concordance of Doppler and BPS test results were examined for the whole patient group and based on delivery prior to 32 weeks' gestation. RESULTS: Abnormal UA Doppler results alone were observed in 109 fetuses (33.2%), brain sparing in 87 (26.5%) and an abnormal DV in 132 (40.2%). The BPS was normal in 158 (48.2%), equivocal in 68 (20.7%) and abnormal in 102 (31.1%). Both testing modalities stratified patients into groups with comparable acid-base disturbance and perinatal outcome. Of the nine possible test combinations the largest subgroups were: abnormal UA alone/normal BPS (n = 69; 21%) and abnormal DV Doppler/abnormal BPS (n = 62; 18.9%). Assessment of compromise by both testing modalities was concordant in 146 (44.5%) cases. In 182 fetuses with discordant results the BPS grade was better in 115 (63.2%, P < 0.0001). Marked disagreement of test abnormality was present in 57 (17.4%) fetuses. Of these, abnormal venous Doppler in the presence of a normal BPS constituted the largest group (Chi-square P < 0.002). Stratification was not significantly different in patients delivered prior to 32 weeks' gestation. CONCLUSION: Doppler ultrasonography and BPS effectively stratify IUGR fetuses into risk categories, but Doppler and BPS results do not show a consistent relationship with each other. Since fetal deterioration appears to be independently reflected in these two testing modalities further research is warranted to investigate how they are best combined.

Is Doppler prediction of anemia effective in the growth-restricted fetus?

OBJECTIVE: To evaluate the utility of middle cerebral artery (MCA) and umbilical artery (UA) Doppler to predict anemia in intrauterine growth restricted (IUGR) fetuses. METHODS: Fetuses with an abdominal circumference < 5th percentile had UA and MCA Doppler prior to delivery. The UA pulsatility index (PI), MCA PI, ratio between the MCA/UA PI (cerebroplacental ratio, CPR) and MCA peak systolic velocity (PSV) were measured. A complete blood count was determined from a peripheral venous sample drawn at delivery. Anemia was defined as a hemoglobin value of < 13 g/dL. MCA PSV Z-scores (standard deviation from gestational age mean using references ranges by Mari et al. and Kurmanavicius et al.) were related to hemoglobin using linear regression analysis. In addition, UA absent end-diastolic velocity (AEDV), brain sparing (MCA PI > 2 SDs below gestational age mean), low CPR (> 2 SDs below gestational age mean) and an elevated MCA PSV (> 2 SDs) were evaluated for their predictive accuracy for anemia. RESULTS: Of 97 IUGR neonates 23 were anemic (23.7%). The MCA PSV was significantly related to hemoglobin using either reference range (Mari et al., F = 22.1577, Kurmanavicius et al., F = 21.8188, P < 0.001, respectively). However, using categorical cut-offs as well as regression analysis none of the Doppler parameters could be identified to provide clinically useful prediction of anemia. CONCLUSION: Parameters of MCA and UA vascular impedance and MCA PSV are significantly related to anemia in IUGR neonates. Despite this relationship the predictive accuracy is unacceptable for the clinical application in the setting of IUGR. Altered cardiovascular dynamics in IUGR fetuses may be responsible for this effect.

Successful intrauterine management of severe feto-fetal transfusion in a monochorionic triplet pregnancy using bipolar umbilical cord coagulation.

Triplet-to-triplet transfusion is a rare clinical complication of monochorionic pregnancies. We present such a case in a monochorionic triamniotic triplet gestation. After a single fetal demise an ongoing twin-to-twin transfusion continued in the surviving triplets. The donor triplet had ultrasound evidence of secondary structural brain damage. The pregnancy was successfully managed with bipolar umbilical cord coagulation of the donor triplet and spontaneous vaginal delivery of the recipient triplet. The case highlights the clinical spectrum and diagnostic and management options that present themselves in these high-risk pregnancies.

Prevalence of viral DNA in amniotic fluid of low-risk pregnancies in the second trimester.

AIM: The association between fetal viral infection and adverse pregnancy outcome is well documented. However, the prevalence of common viral pathogens in the amniotic fluid of normal pregnancies is not established. The purpose of this study was to determine this prevalence in asymptomatic patients. METHODS: This was a prospective observational study of patients at low risk for viral infection who were referred for second-trimester genetic amniocentesis. In patients with normal fetal anatomy on ultrasound and a normal fetal karyotype, a 2-ml aliquot of amniotic fluid obtained at amniocentesis was analyzed by multiplex polymerase chain reaction for cytomegalovirus (CMV), parvovirus B19, adenovirus, enterovirus, herpes simplex virus (HSV), respiratory syncytial virus (RSV) and Epstein-Barr virus (EBV). RESULTS: Among 686 patients, advanced maternal age was the most common indication for genetic testing (n = 469, 68.4%), followed by elevated aneuploidy risk on triple screen (n = 164, 23.9%), elevated maternal serum alpha-fetoprotein (n = 20, 2.9%), previous aneuploidy (n = 16, 2.3%) and family history of inheritable disease (n = 14, 2.1%). Forty-four (6.4%) amniotic fluid samples were positive for viral genome. A single genome was amplified in 41 samples (93%). In three samples, two viral genomes were identified. Adenovirus was most frequently identified (37/44), followed by CMV (5/44), EBV (2/44), enterovirus (2/44) and RSV (1/44). Parvovirus and HSV were not identified. There was a bimodal seasonal variation in prevalence, with the highest prevalence during the summer and late winter. CONCLUSION: Viral genome is commonly found in amniotic fluid with a sonographically normal fetus, and the prevalence follows a seasonal pattern. The mechanism, significance and effects of this asymptomatic viral presence require further study.

Qualitative venous Doppler waveform analysis improves prediction of critical perinatal outcomes in premature growth-restricted fetuses.

BACKGROUND: Our aim was to test the hypothesis that qualitative ductus venosus and umbilical venous Doppler analysis improves prediction of critical perinatal outcomes in preterm growth-restricted fetuses with abnormal placental function. METHODS: Patients with suspected intrauterine growth restriction (IUGR) underwent uniform fetal assessment including umbilical artery (UA), ductus venosus (DV) and umbilical vein (UV) Doppler. Absent or reversed UA end-diastolic velocity (UA-AREDV), absence or reversal of atrial systolic blood flow velocity in the DV (DV-RAV) and pulsatile flow in the umbilical vein (P-UV) were examined for their efficacy to predict critical outcomes (stillbirth, neonatal death, perinatal death, acidemia and birth asphyxia) before 37 weeks' gestation. RESULTS: Seventeen (7.6%) stillbirths and 16 (7.1%) neonatal deaths were observed among 224 IUGR fetuses. Forty-one neonates were acidemic (19.8%) and seven (3.1%) had birth asphyxia. Logistic regression showed that UA-AREDV had the strongest association with perinatal mortality (R(2) = 0.49, P < 0.001), stillbirth (R(2) = 0.48, P < 0.001) and acidemia (R(2) = 0.22, P = 0.002) while neonatal death was most strongly related to DV-RAV and P-UV (R(2) = 0.33, P = 0.007). UA waveform analysis offered the highest sensitivity and negative predictive value and DV-RAV and P-UV had the best specificity and positive predictive values for outcome prediction. Overall, DV-RAV or P-UV offered the best prediction of acidemia and neonatal and perinatal death irrespective of the UA waveform. In fetuses with UA-AREDV, prediction of asphyxia and stillbirth was significantly enhanced by venous Doppler. CONCLUSION: Prediction of critical perinatal outcomes is improved when venous and umbilical artery qualitative waveform analysis is combined. The incorporation of venous Doppler into fetal surveillance is therefore strongly suggested for all preterm IUGR fetuses.

Antenatal prediction of intraventricular hemorrhage in fetal growth restriction: what is the role of Doppler?

OBJECTIVE: To evaluate relationships between neonatal intraventricular hemorrhage and altered brain blood flow in preterm growth-restricted fetuses. METHODS: One hundred and thirteen growth-restricted fetuses (birth weight < 10th centile and umbilical artery pulsatility index > two standard deviations above gestational age mean) which delivered prematurely (< 34.0 weeks) were studied. Three expressions of altered brain blood flow were defined: 'brain sparing'= middle cerebral artery pulsatility index > two standard deviations below the gestational age mean, 'centralization' = ratio of middle cerebral artery/umbilical artery pulsatility indices (cerebroplacental ratio) > two standard deviations below the gestational age mean, and 'redistribution' = absent or reversed umbilical artery end-diastolic velocity. Intraventricular hemorrhage was graded after Papile (I-IV) by cranial ultrasound performed within 7 days of delivery. RESULTS: Sixty-seven (59.3%) fetuses had brain sparing, 84 (74.3%) had centralization and 51 (45.1%) had redistribution. Fifteen (13.3%) neonates had intraventricular hemorrhage and were more likely to have a biophysical profile < 6, earlier delivery for fetal indications, lower cord artery pH, HCO3, hemoglobin, and platelets, a 10-min Apgar score < 7 and high perinatal mortality (5/15; 33.3%). No associations between intraventricular hemorrhage and brain sparing or centralization were identified. However, neonates with intraventricular hemorrhage had significantly higher umbilical artery pulsatility index deviations from the gestational age mean and a relative risk of 4.9-fold for intraventricular hemorrhage with redistribution (95% confidence interval, 1.5-16.3; P < 0.005). Multiple logistic regression revealed significant associations between intraventricular hemorrhage and a low 10-min Apgar score (r = 0.30, P < 0.005) and low hemoglobin (r = 0.28), gestational age at delivery (r = 0.25) and birth-weight centiles (r = 0.23) (P < 0.05). No Doppler parameter was identified as an independent contributor to intraventricular hemorrhage. CONCLUSION: While loss of umbilical artery end-diastolic velocity early in gestation significantly increases the risk for neonatal intraventricular hemorrhage, prematurity and difficult transition to extrauterine life remain the most important determinants of intraventricular hemorrhage.

Prenatal diagnosis of ventriculocoronary fistula.

BACKGROUND: Cardiac anomalies may be associated with abnormal coronary vascular connections. We report the prenatal diagnosis of ventriculocoronary fistula in three fetuses with associated cardiac anomalies. MATERIALS AND METHODS: Fetal echocardiography was performed in three patients referred for suspected cardiac anomaly. Two-dimensional fetal echocardiography was complemented by color Doppler flow imaging and spectral Doppler in all cases. RESULTS: A ventriculocoronary fistula was diagnosed in three patients referred at 22, 23 and 32 weeks. The first patient had hypoplastic left heart associated with transposition of the great arteries and pulmonary atresia with an intact interventricular septum. The coronary fistula arose from the transposed aorta to the left ventricle. In two patients ventriculocoronary fistula was found in association with pulmonary atresia and an intact interventricular septum. In all cases there was bidirectional flow within the fistula (diastolic blood flow towards the ventricle with reversal during ventricular systole). The pregnancy with hypoplastic left heart with transposition, and one of those with pulmonary atresia resulted in neonatal death and stillbirth, respectively. In the third instance the ventriculocoronary fistula was verified by postpartum cardiac angiography. The infant initially received a Blalock-Taussig shunt, subsequently replaced by a bidirectional Glenn shunt, and was doing well at the time of writing. CONCLUSION: A ventriculocoronary fistula can be identified prenatally by color and spectral Doppler. This anomaly should be sought in fetuses with outflow tract obstructive cardiac lesions and an intact interventricular septum. Prenatal diagnosis allows early angiography postnatally. Delineation of coronary vascular regions may therefore facilitate preoperative planning.

Antenatal assessment of the growth restricted fetus.

Babies who are small due to intrauterine growth restriction are at higher risk for poor perinatal and long-term outcome than those who are appropriately grown. Through multiple antenatal testing modalities a sequence of deteriorating fetal status can be documented in such cases. The nature of this compromise is best reflected by the combination of fetal biometry, biophysical profile scoring and arterial and venous Doppler. This combination accurately defines fetal states and therefore risk of stillbirth or poor transition to extrauterine life. In the preterm neonate, fetal factors, gestational age and neonatal course interact significantly to impact on short- and long-term outcomes. The potential for iatrogenic prematurity is great and ongoing appraisal of peripartum management is critical. An integrated management protocol accounting for these factors is examined in this review.

The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens.

OBJECTIVE: To test the hypothesis that hemodynamic changes depicted by Doppler precede deteriorating biophysical profile score in severe intrauterine growth restriction. METHODS: Intrauterine growth-restricted fetuses with elevated umbilical artery Doppler pulsatility index (PI) > 2 standard deviations above mean for gestational age and birth weight < 10th centile for gestational age were examined longitudinally. Fetal well-being was assessed serially with five-component biophysical profile scoring (tone, movement, breathing, amniotic fluid volume and non-stress test) and concurrent Doppler examination of the umbilical artery, middle cerebral artery and ductus venosus, inferior vena cava and free umbilical vein. For fetuses with a final biophysical profile score < 6/10, progression of biophysical profile scoring, arterial PI and venous peak velocity indices were analyzed longitudinally. Gestational age effect was removed by converting indices to Z-scores (deviation from gestational age mean, in standard deviations). RESULTS: Forty-four of 236 intrauterine growth-restricted fetuses (18.6%) required delivery for abnormal biophysical profile scoring. The median gestational age at entry was 25 weeks and 1 day and at delivery was 29 weeks and 6 days. The median interval between examinations was 1.5 days and the majority had daily testing in the week prior to delivery. Between first examination and delivery, significant deterioration was observed for Doppler criteria (chi-square, P < 0.001) and biophysical parameters (Fisher's exact, P = 0.02) predominantly confined to the week prior to delivery/stillbirth. Doppler variables changed first. In 42 fetuses (95.5%), one or more vascular beds deteriorated, accelerating especially in the umbilical artery and ductus venosus at a median of 4 days before biophysical profile scoring deteriorated. Two to 3 days before delivery, fetal breathing movement began to decline. The next day, amniotic fluid volume began to drop. Composite biophysical profile score dropped abruptly on the day of delivery, with loss of fetal movement and tone. Three principal patterns of Doppler deterioration were observed: (i) worsening umbilical artery PI, advent of brain sparing and venous deterioration (n = 32, 72.7%); (ii) abnormal precordial venous flows, advent of brain sparing (n = 6, 13.6%); and (iii) abnormal ductus venosus only (n = 4, 9.1%). In the majority (31, 70.5%), Doppler deterioration was complete 24 h before biophysical profile score decline. In the remainder (11, 25%), Doppler deterioration and biophysical profile score < 6/10 were simultaneous. CONCLUSION: In the majority of severely intrauterine growth-restricted fetuses, sequential deterioration of arterial and venous flows precedes biophysical profile score deterioration. Adding serial Doppler evaluation of the umbilical artery, middle cerebral artery and ductus venosus to intrauterine growth restriction surveillance will enhance the performance of the biophysical score in the detection of fetal compromise and therefore optimizing the timing of intervention.