Objective: The measurement and evaluation of ductus venosus (DV) blood flow velocity waveform in high-risk pregnancies has been studied intensively in recent years in order to find a more intermediate signal of fetal compromise. Our objective was to study the fetal outcome of pregnancies with intrauterine growth retardation (IUGR) and normal pulsatility of DV compared to an IUGR group with increased DV pulsatility. Methods: The outcome of 42 fetuses before 32 weeks of gestational age without chromosomal or structural aberrations was analyzed. All fetuses showed IUGR <5th percentile based on placental insufficiency diagnosed by pathologic RI >90th percentile of both maternal uterine arteries. One group (30 fetuses; mean weight 730 g/SD 190 g; mean gestational age 197 days/SD 12 days) showed normal, the other (12 fetuses, mean weight 675 g/SD 179 g; mean gestational age 198 days/SD 12 days) reduced, but neither absent nor reverse DV flow during atrial contraction. All 42 fetuses were delivered by cesarean section because of severe variable or prolonged decelerations. We measured blood flow velocities of the DV in every fetus on an average 3.7 days (range 1–5 days) before cesarean section. Fetal outcome was determined by Apgar scores after 5 and 10 min, arterial pH and base excess; neonatal morbidity was recorded by intensive follow-up. Results: There were no significant differences of pH, umbilical artery base excess, Apgar scores and severe neonatal complications between the two groups. Conclusions: Our own data show no correlation between increased pulsatility in the DV (without absent or reverse flow during atrial contraction) and fetal outcome before 32 gestational weeks, even in cases of severe growth restriction based on placental insufficiency. Therefore in these cases reduced DV flow during atrial contraction should cautiously be interpreted regarding obstetrical decisions.

ZusammenfassungFragestellung: Inwieweit besteht eine Korrelation zwischen einer pathologischen Durchblutung der uterinen Arterien ± gemessen mit Hilfe der Doppler-Sonographie zwischen der 18 + 0 ± 23 + 6 SSW ± und sich entwickelnden Schwangerschaftskomplikationen (hypertensive Erkrankungen einschlieûlich HELLP-Syndrom, intrauterine Wachstumsrestriktion, Frühgeburt vor der abgeschlossenen 34. SSW). Methodik: Bei 780 Schwangeren wurde im Rahmen des Fehlbildungsultraschalls eine Doppler-Untersuchung beider Aa. uterinae durchgeführt und der RI berechnet. Von 645 Schwangeren konnten alle relevanten Daten über Schwangerschaftsverlauf und -ausgang erhoben werden. 39 Fälle wurden aufgrund von maternalen oder fetalen Erkrankungen aus der Studie ausgeschlossen. Die verbleibenden 606 Patientinnen wurden in ein Normalkollektiv (n = 536) und ein Risikokollektiv (n = 66) eingeteilt. Für den RI wurden verschiedene Cut-off-Werte (70., 80., 90. Perzentile, Notch bilateral und 95. Perzentile unilateral) und die richtig und falsch positiven bzw. die richtig und falsch negativen berechnet. Ergebnisse: Die Sensitivität erreichte bei der 70. Perzentile als Cut-off-Wert mit 47% den höchsten Wert. Für die 90. Perzentile ergaben sich mit einer Spezifität von 98% und einer positiven Vorhersage von 70% die besten Ergebnisse bei einer Sensitivität von 32%. Mit der 80. Perzentile als Cut-off-Wert zeigte sich, dass die intrauterine Wachstumsrestriktion und die Frühgeburt mit 76% respektive 70% (Sensitivität) erkannt wurden. Für die hyper- AbstractPurpose: Does a correlation exist between the development of pregnancy complications (hypertensive disease including HELLP-sydrome, IUGR < 5th centile and premature birth < 34 completed weeks) and uterine artery Doppler velocimetry from 18 + 0 to 23 + 6 weeks? Material and Methods: 780 pregnant women were examined during a detailed ultrasound scan for the exclusion of fetal malformations. Resistance-Index (RI) was calculated from both right and left uterine arteries. Data concerning course and outcome of pregnancy was complete in 645 cases. We excluded 39 cases because of maternal diseases and divided 606 cases into a ªnormalº group (no pregnancy complication and sufficient fetal outcome; n = 536) and a ªpathologicº group (above mentioned pregnancy complications/insufficient fetal outcome; n = 66). We chose the 70th, 80th, 90th centile of the RI and the Notch as bilateral criterion and the 95th centile as unilateral criterion and calculated the true positive and negative and the false positive and negative values for all of them. Results: A sensitivity of 47% was proved to be the highest value using the 70th centile as cut-off. With the 90th centile as cut-off, a specificity of 98% and a positive predictive value of 70% were best. Using the 80th centile as cut-off, IUGR and premature birth were predicted correctly in 76% and 70%, respectively. Hypertensive disease was indicated in 43%. Specificity was 92% in all these cases. Originalarbeit 49Institutsangaben

The ductus venosus (DV) connects the intra-abdominal umbilical vein with the infundibulum of the IVC and develops during pregnancy to a trumpet-shaped structure with a narrow isthmus that accelerates the blood jet crossing the IVC directly to the left atrium via the foramen ovale avoiding mixing with deoxygenated blood from the right chamber. In animal studies, blood flow and doppler sonographically analyzed blood flow velocity waveforms mainly is controlled by heart rate and central venous pressure. The velocity waveform of the DV contains two peak components: the first indicates systolic velocity of the ventricle, the second peak diastolic velocity. A nadir is seen during atrial contraction. In animal studies, DV blood velocity in hypoxemia is influenced by central venous pressure and heart rate. The determination of the DV/UV ratio reflects the redistribution of blood flow, increases in hypoxemia and is therefore more reliable than blood velocity measurement for the detection and evaluation of fetal distress. In cases with severely growth-restricted fetuses, recipient twin in TTTS (twin-to-twin transfusion syndrome), tachyarrhythmia-induced cardiomyopathia and congenital heart disease, the measurement and interpretation of DV Doppler waveform pulsatility seems to be a useful tool that provides important information on the fetal condition and outcome. In cases of zero or reverse flow during atrial contraction in most cases the delivery of the fetus is indicated. An improvement of morbidity and mortality using Doppler sonography of the DV has not yet been proven. In cases of fetuses with or without chromosomal aberrations with major defects of the heart it can be used in addition to the standard screening methods of the first trimester of pregnancy for detection of heart failure.

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