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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5817_Библиотеки_им_академика_М_И_Перельмана-1.pdf
Doppler Sonography of the Fetal Venous Circulation
3
Fig. 18.15 Abnormal blood flow in the DV with reduced ES
blood flow and RF in marked placental insufficiency.
Knowledge of the underlying disease is important
and decisive in the interpretation of the venous flow
curve, for, as explained above, both a raised cardiac
preload and a cardiac afterload due to severe placental
insufficiency lead to an increase in A blood flow; the
impairment in cardiac function is more severe in the
latter case.
In our own studies of the RHV we added the calculation of ES blood flow (Hofstaetter et al. 1996), and we
found that there was also a significant decrease in ES
blood flow with increasing cardiac afterload. This was
due to marked placental insufficiency, especially in
myocardial dysfunction based on hypoxia. When the
load on the heart was simply due to increased volume,
18.18).
ES flow was not impeded (
At this time Doppler ultrasound of the fetal v.’s is
used to monitor premature fetuses with advanced
placental insufficiency, i.e., with ES blood flow
Fig.
164
Fig. 18.16 Abnormal blood flow in the hepatic v.’s in a case of
cardiac malformation with cardiac insufficiency and hydrops
fetalis.
Fig. 18.18 Abnormal blood flow in the hepatic v.’s with negative ES blood flow and increased A blood flow.
Fig. 18.17 Abnormal blood flow in the DV of an acceptor twin
in a twin-to-twin transfusion syndrome (TTTS).
throughout diastole or reverse flow in the umbilical a.
Experience so far has shown that the hearts especially
of fetuses younger than 30 completed weeks of gestation can withstand this fragile situation for some time.
Deterioration of venous blood flow indicates that such
a heart-sparing effect has come to an end and antedates an abnormal cardiotocogram(CTG) by one to two
days.
A fetus older than 31 weeks of gestation can decompensate much more rapidly and should be delivered
prematurely if there is reverse flow in the umbilical a.,
while venous Doppler readings and the CTG remain
normal. This is especially true since the risks of prematurity are meanwhile much diminished (Hecher et
al. 1995).
In cases of right heart overload due to hypervolemia
Doppler sonography of the venous system is helpful in
monitoring and also allows the prognosis for the pregnancy to be assessed. Here, too, the decision regarding
how to manage the pregnancy must be made individually on a case by case basis.
The application of Doppler sonography of the veins
is much simpler in cardiac arrhythmias. Since the precordial v.’s reflect the filling and emptying of the heart,
the extra contractions of the atrium and ventricles elicit characteristic changes in venous blood flow.
In supraventricular extrasystoles (SVES) the atrium
contracts prematurely during ventricular systole. Since
the AV valve is closed, blood in the veins is turned back
and flow reversal becomes evident during the prolonged S blood flow. Because the whole cardiac cycle is
prolonged, this reverse flow, i.e., A blood flow, intensi-
18.19).
fies during atrial contraction (
In ventricular extrasystoles (VES), by contrast, for-
ward flow to the heart remains unimpeded during
ventricular systole and early diastole, while A blood
flow increases. The premature ventricular contraction
takes place while the AV valves are still open and the
atria are contracting, thus the increase in right atrial
volume leads to a stronger reverse flow into the veins.
Supraventricular tachycardia (SVT) is associated
with a biphasic venous blood flow, the forward flow
being broader, while the reverse flow is narrower, but
intensified (Fig. 18.20).
In bradycardia atrial filling time is prolonged, leading to a somewhat intensified reverse flow, while AV
block shows variable intervals between S blood flow
and D blood flow.
Fig.
Summary
Fig. 18.19 Alteration of a venous blood flow curve by SVES.
Advanced Topics
Fig. 18.20 Alteration of a venous blood flow curve by SVT.
Summary
Venous Doppler ultrasound is a useful complement to
arterial Doppler ultrasound in selected cases of fetal
distress, for example, in marked placental insufficiency
with circulatory centralization and increased volume
load on the heart, or in arrhythmias.
The procedure offers an effective and fascinating insight into the physiology and pathophysiology of the
fetal heart and circulatory regulation. Every case, often
every examination, is instructive, but it takes years of
experience to evaluate the exact role and significance
of venous blood flow.
165
3
166
19 Seven Cases Illustrating the Use of Doppler Ultrasound in
Obstetrics
1—Fetal Growth Restriction
Patient A, gestational age: 29 weeks 5 days
Clinical findings: First presentation for growth
retardation of three weeks;
symmetrical; mild proteinuria.
Age 36; gravida 1, para 0;
blood pressue (BP) normal
range; cardiotocogram (CTG)
normal.
Ultrasound findings: No evidence for malformation;
estimated weight by ultrasound 1000 g (ideal weight
1400 g).
Doppler findings: Zero flow in umbilical a. (UA),
with control (Fig. 19.1a, b);
19.1c);
zero flow in aorta (
brain sparing (Fig. 19.1d); bilateral uterine a. notch and abnormally raised pulsatility
index (PI) (Fig. 19.1e, f).
Assessment: Early fetal growth restriction
with impaired uteroplacental
perfusion and consequent feto-
Fig.
Course: Hospitalized with bed rest
Result: Girl, 980 g; Apgar 5−8−8 (1−5−
placental perfusion impairment, centralization of fetal
circulation; still compensated.
until 30 weeks 4 days;
BP intermittently to 160/100.
At 30 weeks 6 days increasingly silent CTG showing
decelerations without uterine
contractions.
In view of unripe cervix, primary section was performed.
10minutes) UA pH 7.23; base
excess (BE) −4.5 mmol/L.
Development good with rapid
weight increase on neonatal
intensive care.
Jaundice, phototherapy. Dis-
charge after seven weeks
weighing 2550 g.
Advanced Topics
abc
def
Fig. 19.1a−f Doppler ultrasound findings in a case of impaired uteroplacental
perfusion with consequent impairment
of fetoplacental perfusion and centrali-
zation of the fetal circulation due to
early fetal growth restriction. The condition is still compensated.
a Zero flow in the UA.
b Zero flow in the UA (control).
c Zero flow in the aorta.
d Brain sparing.
e Right uterine a. with notch and ab-
normally elevated PI.
f Left uterine a. with notch and abnor-
mally elevated PI.
167
3
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
2—Extreme Fetal Growth Restriction Due to Endarteritis Obliterans
Patient B, gestational age: 28 weeks 3 days
Clinical findings: Age 22, gravida 2, para 0, sta-
tus post intrauterine death at
18th week of pregnancy two
years ago. Initial presentation
for oligohydramnios; CTG
shows silent oscillations.
Ultrasound findings: Extreme growth retardation of
six to seven weeks, anhydramnios, estimated weight by ultrasound 쏝300 g; mild pericardial effusion.
Doppler findings: Zero to reverse flow in the UA
ig.
F
19.2a); zero flow in the
(
aorta (Fig. 19.2b); brain sparing
(Fig. 19.2c); abnormal flow in
the inferior vena cava (IVC)
(Fig. 19.2d); uteroplacental
flow unremarkable (Fig. 19.2e).
Assessment: Unfavorable prognosis due to
extreme maldevelopment.
No clear obstetric basis for
decision concerning the child.
Consultation included mother
and pediatrician, consensus re-
garding expectant treatment.
Course: After three days intrauterine
death confirmed; prostaglandin induction.
Result: Spontaneous delivery 290 g; no
malformation; placenta shows
severe endarteritis obliterans.
ab
c
d
Fig. 19.2a−e Doppler ultrasound findings in extreme growth restriction with
poor prognosis.
a Zero and reverse flow in the UA.
b Zero flow in the aorta.
c Brain sparing.
d Abnormal flow in the IVC.
e No abnormal finding in utero-
placental flow.
168
e
3—Exclusion of Potter Syndrome
Patient C, gestational age: 26 weeks 4 days
Clinical findings: Age 26, gravida 1, para 0.
First presentation for suspected Potter syndrome due to
decreased amniotic fluid.
Ultrasound findings: Anhydramnios, disproportional
growth restriction, head
diameters appropriate to gestational age, thorax retarded
by two weeks, weight estimated by ultrasound 800 g;
kidneys were displayed by
color Doppler bilaterally
(Fig. 19.3a, b).
Doppler findings: Reverse flow in the UA
ig.
F
19.3c); reverse flow in the
(
aorta (Fig. 19.3d); brain sparing
(Fig. 19.3e); abnormal uteroplacental perfusion bilaterally
with notch (Fig. 19.3f, g).
Evaluation: No Potter syndrome; severe
uteroplacental and fetoplacental perfusion impairment with
centralization of the circulation.
3—Exclusion of Potter Syndrome
Course: Evening CTG showed “bird’s wing”
pattern (i.e., CTG looks like the silhouette of birds flying as seen from
a distance; a typical CTG pattern
correlated to fatal hypoxia) with
silent oscillation and spontaneous
contractions (Fig.
section with biopsy of the placental
bed (i.e., uterine tissue adjacent to
placental insertion).
Result: 760g, no malformations (Fig. 19.3i).
Apgar 4 (1 minute): primary intubation
UA pH 7.18, BE −10 mmol/L.
Placenta 80 % infarcted, with old
and recent infarcts.
Placental bed biopsy showed predominantly eccentric narrowing and
occlusion of the lumen of the spiral
aa., with hypertrophy of the media
and fibroblastic proliferation
(Fig. 19.3k).
19.3h). Emergency
Advanced Topics
abc
def
Fig. 19.3a−k Fndings in severe impairment of uteroplacental and fetoplacental perfusion with centralization of the
circulation.
a Sonographic image of a fetal kidney.
b Color Doppler image of renal arter-
ies.
c Reverse flow in the UA.
d Reverse flow in the aorta.
g
e Brain sparing.
f Abnormal perfusion with notch in
the right uterine a.
g Abnormal perfusion with notch in
the left uterine a.
169
3
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
fi
j
k
Fig. 19.3h CTG. “Bird’s wing” pattern
with silent oscillation
i Newborn infant, 760 g, Apgar 4, pri-
mary intubation required.
j Placenta showing old and more re-
cent infarctions, in total 80 % infarcted.
k Placental bed biopsy histology shows
predominantly eccentric narrowing
of the lumen and occlusion of the
spiral arteries, media hypertrophy,
and proliferation of fibroblasts.
170
4—Closely Coordinated Preventive Care for High-Risk Patients
4—Closely Coordinated Preventive Care for High-Risk Patients
Patient D, gestational age: 6−38 weeks
History: Age 32, gravida 3, para 2
Status post stillbirth at 33
weeks of gestation with severe
growth restriction and placental insufficiency.
Status post cesarean section
for severe preeclampsia at 27
weeks. Infant was severely
growth restricted and soon
died. Intense desire for a living
child.
Advice: Closely coordinated preventive
pregnancy monitoring, course
followed by Doppler. Acetylsalicylic acid (ASA) from 6th
week of pregnancy.
Doppler findings: Uteroplacental perfusion was
Course: ASA discontinued at 36th week
Result: Infant 2870 g, continued good
appropriate and adapted to gestational age 6th to 38th week
Fig.
of pregnancy (
19.4a−f).
(risk of cerebral hemorrhage in
the infant). At 38 weeks secondary cesarean section for
dystocia.
development, normal discharge.
Advanced Topics
Fig 19.4a−f Doppler ultrasound display of the right uterine a. during
timely and normal adaptation of
uteroplacental perfusion from the 6th
to 38th weeks of gestation.
a Gestational age: 6 weeks 5 days.
b Gestational age: 9 weeks 5 days.
c Gestational age: 13 weeks 6 days.
d Gestational age: 17 weeks 6 days.
e Gestational age: 20 weeks 3 days.
f Gestational age: 38 weeks 4 days.
a
c
b
d
171
e
f
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
5—Patient with Antiphospholipid-Antibody Syndrome
Mrs. T.M., age 31, gravida 4, para 4, status post three
stillbirths (24 weeks, 700 g, 25 weeks of gestation,
weight unknown), with known antiphospholipid-antibody syndrome. From the beginning of pregnancy
patient received 100 mg ASA daily and metoprolol tab
1 q.d. Outpatient ultrasonic monitoring was performed
at two-week intervals. Because of the significant history the patient was admitted from the 28th week of
pregnancy. Initially growth was normal by ultrasound,
but from the 30th week of pregnancy growth began to
Fig.
19.5a, b). The uteroplacental Doppler find-
3
slow (
ings were always abnormal, showing notches. The
notches were more marked from the 28th week on.
The resistance indices of the UA and the aorta were in
the upper normal range until the 32nd week of gestation, after which the aorta exhibited a block and the
umbilical a. a very high resistance index (RI). The RI of
the middle cerebral a. (MCA) declined continuously, a
sign of centralization (Figs. 19.6−19.11). There was no
tricuspid incompetence and there were no abnormal
flow readings in the course of the pregnancy
(Fig. 19.12). The increasing centralization led to the
decision to perform a primary section at 33 weeks 4
days.
Infant male, 1680 g (normal) Apgar values 9−10−10,
UA pH 7.29. The infant was kept on inpatient care for
about four weeks and was discharged in good general
condition.
The mother’s immediate postoperative course was
unremarkable, and she was discharged on the 13th
postoperative day. Ten days after discharge the patient
spiked a fever of 쏜 100 °F with pleuropneumonia at
the left base. Further examination revealed a deep vein
thrombosis of the pelvis and leg veins and necrosis of
the thigh consequent on thrombocytopenia type II associated with heparin (HIT-II). Excision of necrotic
tissue from the left thigh and a mesh graft were required. The patient was discharged four months after
delivery.
12
10
8
6
+
BPD
cm
FL
cm
+
4
2
0
12 16 20 24 28 32 36 40
a
12
10
8
6
4
2
0
12 16 20 24 28 32 36 40
b
Fig. 19.5a Biparietal diameter (BPD) and femur length (FL)
throughout the course of pregnancy.
Fig. 19.5b Abdominal diameter (AD) throughout the course
of pregnancy
Weeks of gestation
Weeks of gestation
AD
cm
+
172
5—Patient with Antiphospholipid-Antibody Syndrome
Fig. 19.6a−d Doppler ultrasound
readings through the course of pregnancy.
a RI of the UA.
b RI of the MCA.
c Placental−cerebral ratio (PCR) (RI
umbilical a./RI middle cerebral a.)
d RI of the uterine a. (UT).
1.0
1.0
+
+
0.5
0
24 27 30 36 39 42
RI of UA
a
1.5
33
Weeks of
gestation
0.5
0
b
RI of MCA
3324 27 30 36 39 42
+
1.0
1.0
+
0.5
0
PCR
cd
3324 27 30 36 39 42
Weeks of
gestation
0.5
0
3324 27 30 36 39 4215 18 21
RI of UT
Weeks of
gestation
Advanced Topics
Weeks of
gestation
Fig. 19.7a−e Doppler sonographic
display of the right uterine a. through
the course of pregnancy: PI values
tend to increase, notch intensity increases, an additional (double notch)
systolic notch appears as the pregnancy progresses.
a Gestational age: 22 weeks 5 days,
minimal postsystolic notch, PI:
1.05.
b Gestational age: 25 weeks 0 days,
minimal postsystolic notch, PI:
1.22.
c Gestational age: 27 weeks 2 days,
minimal postsystolic notch, PI:
1.53, systolic notch (double notch).
d Gestational age: 32 weeks 3 days,
minimal postsystolic notch, PI:
1.30, systolic notch.
e Gestational age: 33 weeks 3 days,
very marked postsystolic notch, PI
1.45, systolic notch.
ab
cd
173
d