Reversed end-diastolic umbilical flow in a first-trimester fetus with congenital heart disease

Reversed end-diastolic flow in the umbilical artery at 10-14 weeks of gestation is associated with absent pulmonary valve syndrome

OBJECTIVE

To determine the incidence of reversed end-diastolic flow (REDF) in the umbilical artery in high-risk first-trimester pregnancies and evaluate associated conditions.

METHODS

This was a prospective evaluation of the umbilical artery Doppler waveforms of 614 consecutive high-risk pregnancies between 10 and 14 weeks of gestation, to determine those with REDF. The associated anomalies and characteristics of these fetuses were then investigated.

RESULTS

In 278/614 (45.3%) fetuses, there was positive end-diastolic flow in the umbilical artery; in 331/614 (53.9%) end-diastolic flow was absent and in 5/614 (0.8%) there was REDF. Three of the five fetuses with REDF had tetralogy of Fallot (TOF) with absent pulmonary valve syndrome (APVS) and a patent ductus arteriosus, and all three showed signs of cardiac failure, with reversed blood flow in the ductus venosus during atrial systole and generalized skin edema. Another fetus had a large ventricular septal defect and the remaining fetus had agenesis of the ductus venosus. Three fetuses had trisomy 18 and one had trisomy 13.

CONCLUSIONS

REDF in the umbilical artery is very rare in early pregnancy and mostly occurs in association with major fetal vascular anomalies and cardiac defects, particularly TOF with APVS and patent arterial duct. We propose that the patency of the arterial duct in TOF with APVS leads to heart failure with subsequent demise early in pregnancy. Therefore, the frequent absence of the arterial duct observed in APVS in later pregnancy is more likely to be a result of early selection than a prerequisite for the development of this lesion as has been proposed previously.

First-trimester reversed end-diastolic flow in the umbilical artery is not always an ominous sign

We report five cases of first-trimester reversed end-diastolic flow in the umbilical artery. Diagnoses were performed between 8 and 12 gestational weeks. All but one case appeared as a transient early finding. Second-trimester fetal demise occurred in two cases. One case delivered at 32 weeks with severe growth restriction but recovered well. The other two cases had a good pregnancy outcome. Our experience suggests that this early Doppler finding is not always an ominous sign.

Diagnosis of congenital cardiac defects between 11 and 14 weeks' gestation in high-risk patients

OBJECTIVE

To examine the feasibility of diagnosing congenital cardiac defects between 11 and 14 weeks' gestation in a high-risk population.

METHODS

Fetal echocardiography was first offered at 11 to 14 weeks' gestation to all patients at risk for congenital heart defects. Echocardiography performed at 11 to 14 weeks with normal results was repeated at 14 to 16 and 20 to 24 weeks. Final diagnoses of cardiac anomalies that had been observed at 11 to 14 weeks were established at 14 to 16 weeks or later Fetal echocardiography performed at 14 to 16 weeks with normal results was repeated at 20 to 24 weeks. Ascertainment of cardiac anomalies was obtained by postnatal echocardiography or pathologic examination of the fetal heart after termination of pregnancy. Most of the examinations were performed transvaginally until 16 weeks. The transabdominal approach was used at this stage only when patients refused the transvaginal examination or because of technical difficulties. Three hundred ninety-two fetal echocardiographic examinations were performed between 11 and 14 weeks' gestation; 438 examinations were performed between 14 and 16 weeks; and 777 examinations were performed between 20 and 24 weeks. The major indications for fetal echocardiography at 11 to 14 weeks were maternal diabetes and previous pregnancy with congenital heart defects.

RESULTS

Six of 7 major fetal cardiac anomalies were detected. The only major cardiac anomaly that was not detected between 11 and 14 weeks was correctly diagnosed at 22 weeks. Only 1 of 5 minor fetal cardiac anomalies was detected between 11 and 14 weeks. Another 2 minor fetal cardiac anomalies were detected at 23 weeks. Four incorrect diagnoses of minor cardiac anomalies were excluded on repeated fetal echocardiography between 20 and 24 weeks.

CONCLUSIONS

The initial attempt to diagnose congenital heart defects should be offered at 11 to 14 weeks' gestation.

Reversed end-diastolic flow in first-trimester umbilical artery: an ominous new sign for fetal outcome

OBJECTIVE

The purpose of this study was to assess the fetal outcome of first-trimester pregnancies with reversed end-diastolic flow in the umbilical artery.

STUDY DESIGN

Doppler studies in the umbilical artery were carried out in 2970 consecutive pregnancies scanned at 10 to 14 weeks.

RESULTS

We observed 11 (0.4%) cases of reversed end-diastolic flow. Of these, an autosomal trisomy was shown in 7 and a congenital heart defect in 2 additional fetuses. Fetal demise was observed in 5 pregnancies, neonatal death was observed in 1, and termination of pregnancy was carried out in 4. Only 1 fetus survived.

CONCLUSIONS

Reversed end-diastolic flow in first-trimester umbilical artery signals an ominous prognosis even with normal karyotype.