Diagnosis of absent ductus venosus in a population referred for fetal echocardiography: association with a persistent portosystemic shunt requiring postnatal device occlusion

Prenatal Detection and Postnatal Outcome of Persistent Left Superior Vena Cava and Agenesis of Ductus Venosus Associated with Postnatal Bovine Aortic Arch

BACKGROUND

Isolated agenesis of ductus venosus (ADV) is usually a benign condition, but it may be associated with cardiovascular defects, hydrops, growth restriction, and chromosomal abnormalities. Additionally, persistent left superior vena cava (PLSVC) and bovine aortic arch are relatively common fetal anomalies. To the author's knowledge, this is the first report of prenatal detection of DV agenesis and PLSVC associated with the postnatal bovine aortic arch with a hypoplastic transverse aortic arch.

CASE

A 25-year-old, G2P1 woman was referred to our department at 31 weeks due to fetal growth restriction and short femur. On fetal echocardiography, DV could not be viewed via two-dimensional (2D) and Doppler ultrasound (US) imaging; there was also evidence of the co-occurrence of PLSVC and an aortic arch anomaly. We revealed the intrahepatic continuation of the umbilical vein. A weekly follow-up program was scheduled for the patient and the rest of the pregnancy was uneventful. Postnatal, thorax computer tomography and transthoracic echocardiography (TTE) demonstrated PLSVC and bovine aortic arch associated with hypoplastic transverse aortic arch. Routine echocardiographic examinations revealed that the blood flow of the aortic arch had increased gradually, and the male infant's aortic arch had significantly widened and reached the normal range until the baby was discharged from the hospital.

CONCLUSION

DV agenesis and PLSVC are usually benign conditions but underlying serious heart diseases may accompany them. Therefore, in situations like ours, a prenatal aortic arch evaluation is of capital importance. Postnatal hemodynamic changes should be taken into consideration in the management of these cases. This is the first example in the literature that these abnormalities co-existed in one case.

Agenesis of the ductus venosus and fetal growth restriction: Is there a relation? A tertiary care center experience and systematic review of the literature

An update on the antenatal diagnosis of agenesis of ductus venosus (ADV) by differentiating the various possible types of shunts, focusing on the associated fetal anomalies, and predicting neonatal outcomes. This study reviewed the experience of two tertiary referral centers and literature. An unfavorable outcome was detected in preterm fetuses (p = 0.017), fetuses with a genetic anomaly (p = 0.046) or other associated malformations (p < 0.001). 71% of ADVs with other anomalies had an extrahepatic ADV (p = 0.002). 76% of fetuses with Fetal Growth Restriction (FGR) had an extrahepatic ADV (p = 0.025). ADV may negatively influence fetal growth in cases with extrahepatic vein drainage.

Prenatal Diagnosis and Outcome of Umbilical–Portal–Systemic Venous Shunts: Experience of a Tertiary Center and Proposal for a New Complex Type

Aims: To share our experience in the prenatal diagnosis of umbilical–portal–systemic venous shunts (UPSVS) and to study the prognostic factors for proper prenatal and perinatal management. Material and Methods: A five-year prospective study regarding the detection of UPSVS was conducted in two referral centers, Medgin Ginecho Clinic and the Prenatal Diagnostic Unit of the tertiary center, University Emergency County Hospital Craiova, Romania. We included in the analysis a series of agenesis of ductus venosus (ADV) cases previously reported by our center. We analyzed the incidence of the UPSVS types, their associations, and outcome predictors. Results: UPSVS were diagnosed in all 16 cases that were presented to our center at the time of first trimester anomaly scan, except one (94.12%). We diagnosed: 19 type I (61.2%), 4 type II (12.9%) and 5 type IIIa (16.1%) UPSVS. In three cases (9.6%) we noted multiple shunts, which we referred to as type IV (a new UPSVS type). Type IIIa-associated fetal growth restriction (FGR) was found in 60% of cases. Major anomalies worsened the outcome. Of the UPVSS cases, 57.1% were associated with PVS anomalies. Genetic anomalies were present in 40% of the tested cases. Conclusions: The incidence of UPSVS in our study was 0.2%. Early detection is feasible. The postnatal outcome mainly depends on the presence of structural, genetic and PVS anomalies. FGR may be associated. The new category presented a poor outcome secondary to poor hemodynamic and major associated anomalies.

An unusual umbilical venous connection to a left posterior intercostal vein

A foetal echocardiogram, in a 27-week foetus referred for cardiomegaly, demonstrated dextrocardia, absence of the ductus venosus, and an unrestricted unusual umbilical venous drainage to a left posterior intercostal vein, which continued to left hemiazygos vein and drained into the coronary sinus. Progressive cardiomegaly led to early delivery. To the best of our knowledge, no case with similar umbilical venous drainage has been previously reported.

Prenatal Ultrasound Analysis of Umbilical-Portal-Systemic Venous Shunts Concurrent With Trisomy 21

OBJECTIVES

A classification termed umbilical-portal-systemic venous shunt (UPSVS) for an abnormal umbilical vein (UV), portal vein (PV), and ductus venosus (DV) was proposed recently. According to this classification, there are 3 types of UPSVSs: types I, II, and III. Trisomy 21 associated with UV-PV-DV anomalies has been described, but the incidence of trisomy 21 in UPSVS cases, the relationship between UPSVS types and trisomy 21, and the pregnancy outcome are poorly documented. This study aimed to address these issues.

METHODS

All UPSVS cases diagnosed at our department from 2016 to 2019 were retrospectively studied. The English literature describing UV-PV-DV anomalies and trisomy 21 from 2000 to 2019 was searched, and the retrieved cases were analyzed.

RESULTS

Four of 20 UPSVS cases identified by us also had trisomy 21, with 2 type I and 2 type II UPSVSs. Ultrasound markers of Down syndrome were observed in all 4 cases that underwent termination of pregnancy (TOP). The literature search retrieved 12 reports including 279 patients, with 29 also having trisomy 21, giving a pooled trisomy 21 incidence rate of 10.4%. Of the 29 cases, 16 had type I, and 9 had type II, whereas UPSVS types in 4 were undeterminable, and 22 cases underwent TOP.

CONCLUSIONS

There is a high incidence of trisomy 21 in UPSVS cases. Trisomy 21 is associated with a type I or II UPSVS. Most cases with the combined defect underwent TOP. These findings may be used to direct prenatal counseling and management of the combined condition.

Pre and postnatal diagnosis of congenital portosystemic shunt: Impact of interventional therapy

INTRODUCTION

Congenital portosystemic shunts (CPSS) are rare vascular malformations that can lead to severe complications. With advanced imaging techniques, diagnosis is becoming more feasible occurring in fetal life. Different approaches have been adopted to manage these cases, with an increased utilization of interventional therapy recently. This cohort aims to describe the course of children diagnosed with CPSS and the impact of interventional therapy on the outcome.

METHODS

Retrospective chart review was done for all patients who were diagnosed with CPSS in our institution between January 2006 and December 2015.

RESULTS

Six patients were diagnosed with CPSS. During this period, 8,680 mothers carrying 9548 fetuses underwent fetal ultrasound examinations. Three patients were diagnosed antenatally at a median [IQ] gestational age of 33 [26-33] weeks, and three patients were diagnosed postnatally at 0, 2, and 43 months, respectively. At a median follow-up of 87 [74-110] months, 5 patients are alive; 4 of whom had received transcatheter closure for different indications, and one who had spontaneous resolution of her CPSS. One infant died at the age of 6 weeks secondary to sepsis.

CONCLUSION

CPSS can result in significant complications in children. Interventional therapy is feasible at any age group, but long-term follow-up is warranted.

A basic understanding of congenital extrahepatic portosystemic shunt: incidence, mechanism, complications, diagnosis, and treatment

Extrahepatic portosystemic shunt belongs to a family of rare vascular abnormalities. The clinical importance and manifestations of this vascular abnormality range from asymptomatic cases to liver or metabolic dysfunctions of various degrees. Congenital extrahepatic portosystemic shunt, also termed as Abernethy malformation, is a very rare congenital vascular malformation in which splenomesenteric blood drains into a systemic vein, bypassing the liver through a complete or partial extrahepatic shunt. So far, limited cases of congenital extrahepatic portosystemic shunt have been reported. In this review, incidence, mechanisms, complications, diagnoses and treatments of congenital extrahepatic portosystemic shunt are described.

Correlations among Congenital Hepatic Shunt, Absent Ductus Venosus, and Umbilical Vein Shunt Revealed by Prenatal Ultrasound

OBJECTIVES

Congenital disruptions of the hepatic vasculature such as hepatic vascular shunt and absence of ductus venosus (ADV) are rare and often asymptomatic. Moreover, hepatic vasculature abnormality, ADV, and umbilical shunt are easily missed during ultrasound screening due to insufficient scope of examination. In our study, we analyzed the associations among congenital hepatic shunt, ADV, and umbilical vein (UV) shunt by prenatal ultrasound screening.

METHODS

This was a retrospective study of 9 cases of congenital hepatic vascular shunt and 14 cases of isolated ADV identified by prenatal ultrasound screening at Chengdu Women and Children's Center Hospital from 2014 to 2018. The review parameters included ultrasound findings of the fetal hepatic vessels, fetal heart, UV, other malformations, complications, and fetal prognosis.

RESULTS

The 9 cases of hepatic shunt included 6 cases of isolated portosystemic shunt, 2 mixed cases of vascular shunt with portosystemic shunt, and 1 case of intrahepatic arteriovenous fistula. Among the 8 total cases of portosystemic shunt, 5 were accompanied by ADV (62.5%). Of the 5 cases of congenital hepatic shunt with ADV, 3 were accompanied by umbilical shunt (60%). Among the 9 cases of hepatic vascular shunt, 6 were accompanied by dilated inferior vena cava and cardiomegaly (66.7%). Of the 19 total ADV cases identified, there were 14 cases without hepatic shunt, 5 with hepatic shunt, and 17 with umbilical shunt (89.4%). Among the 14 ADV cases without hepatic shunt, there were 5 cases with congenital heart defect (35.7%) and 4 with cardiomegaly (28.6%).

CONCLUSIONS

Portosystemic shunt, ADV, and umbilical shunt are closely associated. Appreciation of these associations can improve prenatal ultrasound screening for a timely prognosis and initiation of appropriate treatment.

Fetal case of right atrial isomerism with infracardiac total anomalous pulmonary venous connection and agenesis of the ductus venosus

After birth, the ductus venosus becomes an important route connecting the pulmonary and systemic venous systems for survival in infracardiac total anomalous pulmonary venous connection. We encountered a fetal case of right atrial isomerism with infracardiac total anomalous pulmonary venous connection and agenesis of ductus venosus. Prenatal echocardiography suggested that the fetus had severe pulmonary venous obstruction; however, no obstructive lesions were detected at the level of the vertical vein that drained into the portal veins. Therefore, we concluded that emergency surgical pulmonary venous obstruction release was the only way for the fetus to survive. However, the saturation level was maintained above 70% due to the abundant communications via the hepatic sinusoid over 1 week after birth. In conclusion, hepatic sinusoids can be a sufficient route for pulmonary venous return and may not cause severe pulmonary venous obstruction in infracardiac total anomalous pulmonary venous connection with agenesis of ductus venosus.

Prenatal sonographic characteristics and postnatal outcomes of umbilical-portal-systemic venous shunts under the new in-utero classification: A retrospective study

An in-utero re-classification of umbilical-portal-systemic venous shunt (UPSVS) has recently been proposed. We retrospectively reviewed the sonograms of a large cohort of fetuses, identified and analyzed UPSVS cases, and presented the prenatal sonographic characteristics, birth outcomes, and follow-up results following the new classification system.Sonograms and clinical data of all participants who visited our departments from April 2016 to July 2018 were retrospectively reviewed. Identified cases of UPSVS were analyzed according to the new classification: Type I: umbilical-systemic shunt (USS); Type II: ductus venosus-systemic shunt (DVSS); Type IIIa: intrahepatic portal-systemic shunt (IHPSS) and Type IIIb: extrahepatic portal-systemic shunt (EHPSS). Postnatal follow-ups ranged from 3 months to 1 year.A total of 10 UPSVS cases were identified in 61,082 fetuses: 4 with Type I, 3 with Type II and 3 with Type IIIa. All 4 cases of USS had complete agenesis of the portal venous system, and had the umbilical vein drained into the inferior vena cava. Two USS cases also had trisomy 21. Pregnancy was terminated in all cases with a Type I shunt. Two fetuses with DVSS had normal portal venous system and were born full term. The pregnancy of 1 DVSS case was terminated due to the detection of trisomy 21. Three cases were IHPSS with full-term birth. One had chromosomal abnormality and 1 had surgery to repair the shunt 12-days post birth. In the 2 cases that did not receive repair surgery, sonographic examination revealed the portal-hepatic venous shunt was not closed at the 6-month follow-up period. However, the 1 case that had repair surgery appeared healthy at the 3-month follow-up period.UPSVS is extremely rare. Type I shunts have the poorest prognosis, and the presence of the intrahepatic portal venous system is key to live birth in UPSVS regardless of types. Chromosomal abnormalities and other organ anomalies can occur in any types of UPSVS. Therefore, karyotyping and examination of other organs should be performed once UPSVS is detected.

Echographic features and perinatal outcomes in fetuses with congenital absence of ductus venosus

INTRODUCTION

The purpose of this study was to describe the echographic features and perinatal outcomes of fetuses with absence of ductus venosus.

MATERIAL AND METHODS

Retrospective review of 10 cases with absence of ductus venosus diagnosed by prenatal ultrasonography between January 2014 and February 2016 at a single referral center. Prenatal findings, umbilical shunting type, perinatal outcomes, and autopsy reports were reviewed.

RESULTS

A total of 11 491 fetuses underwent a first- and second-trimester screening during the study period. Ten cases of absence of ductus venosus were diagnosed. All of the fetuses presented an extrahepatic shunt: three fetuses from the umbilical vein to the right atrium and the seven remaining fetuses from the umbilical vein to the inferior vena cava. Major structural defects and fetal effusions were detected in six fetuses. There were two cases of chromosomal abnormalities. Five patients underwent legal termination of pregnancy and five decided to carry to term. In two of these, the absence of ductus venosus anomaly was isolated and had a normal outcome. In the remaining three cases, a follow up of the children showed a variety of adverse outcomes.

CONCLUSIONS

The absence of ductus venosus is associated with high rates of adverse perinatal outcomes. The prognosis for this group of anomalies depends on the additional findings with targeted ultrasound. This pathology should lead to a detailed anatomical study and affected fetuses should be closely monitored for signs of congestive heart failure.

A Newborn with an Alternative Porto-Caval Shunt

Background

Absent ductus venosus (ADV) is a rare condition, but it should be known that this embryonic anomaly may be detected by fetal echocardiographic or newborn ultrasound examinations.

Case Report

We present a baby with an ADV and an accompanying alternative porto-caval shunt between the right portal vein and inferior vena cava detected on postnatal ultrasound examination.

Conclusions

Variations in the fetal umbilical or porto-systemic circulations should be detected by fetal or newborn ultrasound examinations and kept in mind before common interventions such as UV catheterizations.

Fetal Heart Size: A Comparison Between the Point-to-Point Trace and Automated Ellipse Methods Between 20 and 40 Weeks' Gestation

OBJECTIVES

To evaluate whether the global area and circumference of the heart varies between two measurement techniques: the point-to-point trace and the electronic ellipse methods.

METHODS

The epicardial border of the 4-chamber view was measured in 200 fetuses between 20 and 40 weeks' gestation, from which the area and circumference using the point-to-point trace and electronic ellipse were measured. Analysis of variance, correlation, and regression analysis using fractional polynomials and 7 independent variables (head circumference, biparietal diameter, abdominal circumference, femur length, estimated fetal weight, mean ultrasound gestational age, and last menstrual period gestational age) were performed.

RESULTS

The correlation between the mean ultrasound gestational age and last menstrual period gestational age was 0.9880 (5% confidence limit, 0.9716; 95% confidence limit, 0.9880), with an R² of 0.9762. The R² value for the 7 independent variables regressed against the area and circumference using the point-to-point trace and electronic ellipse methods ranged between 0.885 and 0.965. Comparison of Z scores between this study and previous publications demonstrated that there were differences and similarities, depending on whether the area or circumference was measured.

CONCLUSIONS

This study shows high R² values when comparing measurements of the area and circumference against 7 independent variables, irrespective of whether the point-to-point trace or the electronic ellipse method was used to obtain the measurements. A calculator to evaluate the area and circumference is provided, using 7 independent variables from which Z scores and percentiles for individual measurements can be computed.

Predicting outcome in 259 fetuses with agenesis of ductus venosus - a multicenter experience and systematic review of the literature (.)

OBJECTIVE

To evaluate prenatal predictors of postnatal survival in fetuses with agenesis of ductus venosus (ADV).

METHODS

This retrospective study reviewed our experience and the literature between 1991 and 2015. Prenatal findings were evaluated and perinatal morbidity and mortality was documented.

RESULTS

A total of 259 cases were included in the present analysis from our centers and 49 published studies (15 patients from our retrospective cohort review and 244 from literature review). The intrahepatic and extrahepatic shunts were present in 32.0% (73/226) and 67.7% (153/226), respectively. Cardiomegaly (n = 64/259, 24.7%), hydrops (n = 31/259, 12.0%) and amniotic fluid abnormalities (n = 22/259, 8.5%) were among the most frequent initial ultrasound findings. One hundred and forty-seven fetuses (56.8%) had ADV without structural anomalies while 112 (43.2%) had associated anomalies (cardiac anomalies (n = 66), extra-cardiac anomalies (n = 19) and both cardiac and extra-cardiac anomalies (n = 27)). The mean gestational age (GA) at ultrasound diagnosis was 22.9 ± 6.9 weeks while the mean GA at delivery was 34 ± 7.5 weeks. The overall neonatal survival was 57.1% (n = 148/259). The following factors were associated with survival: advanced maternal age, earlier GA at diagnosis, prematurity, increased nuchal translucency, pericardial effusion, associated cardiac defects (especially AVSD), chromosomal abnormalities, hydrops, hygroma and limb anomalies.

CONCLUSION

Fetal hydrops, the presence of associated congenital anomalies and premature delivery are associated with poor prognosis in fetuses with ADV.

Length to width ratio of the ductus venosus in simple screening for fetal congenital heart diseases in the second trimester

Antenatal diagnosis of congenital heart disease (CHD) is still low even though screening was first introduced over 25 years ago. The purpose of our study was to determine the efficacy of a second-trimester prenatal ultrasonographic method of screening for CHD.From September 2012 to September 2013, the length and width of the fetal ductus venosus were measured sonographically in 1006 singleton fetuses, and the ratio of length to width was calculated. The accuracy of each fetal measurement and Doppler ultrasonography were determined. The standard fetal echocardiographic evaluations including 2-dimensional gray-scale imaging, color, and Doppler color flow mapping were performed. The transducer was aligned to the long axis of the fetal trunk to view the ductus venosus in its full length, including the inlet (isthmus) and outlet portions of the vessel. The diameters of the vessel inner wall and mid-point of the ductus venosus were measured using calipers. All scans and fetal measurements were conducted by a registered sonographer with more than 20 years of perinatal ultrasound screening experience.Of the 1006 singleton fetuses between 19 and 28 weeks' gestation, 36 had CHD. The ductus venosus length/width ratio (DVR) for the first CHD screening was extremely sensitive at 88.90%, with a specificity of 99.10% for the cardiac abnormalities included in this study. Chromosomal anomalies accompanied CHD in 0.4% (4/1006) of all cases and 11.11% (4/36) of the CHD cases.The DVR differed significantly between fetuses with CHD and normal fetuses during the second trimester. Careful assessment of the ratio should be a part of the sonographic examination of every fetus. In the case of a small DVR, advanced echocardiography and karyotype analysis should be performed. The ratio is a helpful tool for screening CHD abnormalities prenatally in the Chinese population.

Fetal umbilical-portal-systemic venous shunt: in-utero classification and clinical significance

OBJECTIVES

To review our experience with fetal umbilical-portal-systemic venous shunts (UPSVS), to devise an in-utero classification system, and to analyze their clinical and prognostic characteristics.

METHODS

This was a retrospective review of cases of UPSVS examined at an academic tertiary referral center over the 14-year period from 2001 to 2014 inclusive. The anatomical origin and drainage of the fetal umbilical, portal, ductus venosus and hepatic venous systems, and the integrity of the intrahepatic portal venous system (IHPVS), were assessed using two- and three-dimensional color Doppler sonography. Fetomaternal clinical characteristics and long-term outcome were investigated by means of medical files, imaging documentation and telephone interviews with the mothers.

RESULTS

Forty-four cases with UPSVS were reviewed. Prenatal classification was based on the anatomical origin of the shunt (umbilical, portal or ductal), with cases classified into four types: Type I, umbilical-systemic shunt (n = 9 (20.4%)); Type II, ductus venosus-systemic shunt (n = 19 (43.2%)); and Type III, portal-systemic shunt, divided into two subtypes: Type IIIa, intrahepatic portal-systemic shunt (n = 12 (27.2%)) and Type IIIb, extrahepatic portal-systemic shunt (n = 4 (9.1%)). Each type presented particular clinical and prognostic characteristics. The most important favorable prognostic factors were absence of associated major malformation and presence of the IHPVS. Thus, Type IIIa (intrahepatic portal-systemic shunt) had the best outcome.

CONCLUSIONS

Fetal UPSVS are anomalies with a broad spectrum of manifestations and prognoses. Accurate mapping of the IHPVS is paramount for optimizing prenatal counseling and postnatal care. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Hemodynamic studies of isolated absent ductus venosus

OBJECTIVE

The objective of this article is to evaluate hemodynamic changes among fetuses with isolated absent ductus venosus (IADV) diagnosed by prenatal ultrasonography.

PATIENTS AND METHODS

Fetuses with prenatal diagnosis of IADV were recruited and followed. Hemodynamic assessment was performed in all cases, including measurement of cardiac dimensions, shortening fraction, myocardial performance index, preload index in the inferior vena cava and the presence of venous pulsations in the umbilical vein (UV).

RESULTS

Nine fetuses of IADV were assessed, including six cases with extra-hepatic UV drainage and three with intra-hepatic drainage. All fetuses with extra-hepatic UV drainage showed an elevated preload index in the inferior vena cava, venous pulsations in the UV and cardiomegaly. Of them, four had hydrops, two showed poor cardiac function and three resulted in perinatal mortality. Three cases with intra-hepatic drainage had continuous flow in the UV, normal in all hemodynamic parameters and all survived.

CONCLUSION

Hemodynamic assessment of fetuses with IADV was helpful in predicting the development of hydrops and perinatal mortality. The poor prognostic factors included cardiac overload, cardiomegaly, poor myocardial performance, increased preload, the presence of venous pulsations and extra-hepatic UV drainage. © 2015 John Wiley & Sons, Ltd.

Agenesis of the venous duct: two cases of extrahepatic drainage of the umbilical vein and extrahepatic portosystemic shunt with a review of the literature

Agenesis of the venous duct is a rare congenital anomaly resulting in abnormal drainage of the umbilical vein into the foetal venous circulation. The clinical presentation and prognosis is variable, and may depend on the specific drainage pathways of the umbilical vein. We present two foetuses with agenesis of the venous duct, both associated with a postnatal portosystemic shunt, but with markedly different postnatal clinical courses. We also review all previously reported cases to better characterise this foetal disorder and the prognosis.

Aberrant drainage of the umbilical vein into the coronary sinus without ductus venosus agenesis

We describe a case series of 4 fetuses with ectopic connections of the ductus venosus to the coronary sinus detected prospectively between August 2011 and February 2012 in 2 congenital cardiologic centers. An enlarged coronary sinus alerted the sonographer. Fetal echocardiography showed ectopic connection of the ductus venosus in an enlarged coronary sinus in all 4 cases. To our knowledge, this anatomic form of ectopic umbilical vein drainage has not previously been reported. The infants were doing well. This venous variant should be considered in cases of isolated coronary sinus dilatation after elimination of a left superior vena cava and a totally anomalous pulmonary vein connection.

Diaphragmatic hernia: a postnatal complication of anomalous drainage of the umbilical vein

The ductus venosus (DV) connects the portal venous system to the inferior vena cava. Rarely, the umbilical venous drainage is anomalous, either connecting to the portal sinus within the liver or having an extrahepatic connection, bypassing the liver and draining to one of a variety of sites, including to the heart directly. Prenatally, there is a recognized association of anomalous umbilical venous drainage with aneuploidy and other structural malformations. The fetus may also develop right heart failure because of unregulated volume loading. We report the postnatal development of diaphragmatic hernia in three fetuses with absent DV and umbilical venous drainage to the right atrium directly in two cases and to the coronary sinus in the third. In all fetuses, the abnormality was well-tolerated in pregnancy, with only a modest degree of right heart dilatation. All three neonates underwent repair of the diaphragmatic hernia and made a good recovery.

Agenesis of the ductus venosus-A case with favorable outcome after early signs of cardiac failure

Absence of the ductus venosus (ADV) is a rare vascular anomaly. Its prognosis depends on the pathway of the umbilical flow to the systemic venous circulation, and the presence or absence of associated structural or chromosomal anomalies, sometimes resulting in hydrops fetalis. In cases with isolated ADV in the absence of associated anomalies, survival rates are as high as 85%, depending on the shunt situation. Here, we report a patient with ADV and extrahepatic umbilical vein drainage with favorable outcome after intrauterine reversal of early signs of cardiac failure. Diagnosis was made after the appearance of moderate cardiomegaly in the 25th gestational week. Thus, in the case of cardiomegaly with or without further signs of cardiac failure, ultrasound imaging of the venous duct should be considered.

Shunt diameter in agenesis of the ductus venosus with extrahepatic portosystemic shunt impacts on prognosis

OBJECTIVES

Agenesis of the ductus venosus (ADV) is a rare condition in which there are two variants of umbilical vein drainage: intrahepatic shunt or extrahepatic (portosystemic) shunt. It has been posited that the extrahepatic variant carries a poorer prognosis. However, in the absence of associated anomalies there is still a wide variation in outcome. We evaluated the portal system in cases of ADV and aimed to identify parameters that might predict outcome.

METHODS

We conducted a retrospective study of cases of ADV with extrahepatic shunt that had been examined in two centers, and collected new cases prospectively. The route of the shunt was depicted using two-dimensional (2D) and three-dimensional (3D) ultrasound imaging. In an attempt to characterize portal system and shunt developmental variations and their possible impact on outcome, the diameter of the shunt was compared with the diameter of the umbilical vein and the entire portal vasculature was assessed. Poor outcome was defined as persistent morbidity or fetal or neonatal death.

RESULTS

Twenty-two cases of ADV were identified: nine retrospectively and 13 prospectively. Aberrant shunts from the umbilical vein were identified to the right atrium, coronary sinus, inferior vena cava (IVC) and iliac vein. In seven of 22 cases (32%) a wide connection was observed. In six of these seven cases (86%) the outcome was poor, including four with severe associated anomalies and two with hepatic dysfunction. In five of these cases, cardiomegaly with tricuspid regurgitation was observed, as well as underdevelopment of the portal system. In only five of 15 cases with a narrow shunt (33%) was the outcome poor, and in all five cases the poor outcome was related to associated anomalies.

CONCLUSION

In cases of ADV with extrahepatic shunt, portal system development is impacted by the diameter of the shunt. If the shunt is narrow, the portal system will have developed normally. A wide shunt is associated with underdevelopment or absence of the portal system. In cases of ADV with extrahepatic shunt, prognosis is determined by the severity of associated anomalies, the diameter of the shunt and development of the portal system.

Stenosis of alternative umbilical venous pathways in absence of the ductus venosus

OBJECTIVE

We evaluated fetuses with absence of the ductus venosus (ADV) and restricted alternative umbilical venous pathways.

METHODS

We identified 3 cases that fit our objective. The angles of insonation for spectral Doppler ultrasound interrogation were less than 20 degrees in all cases. We used commercially available ultrasound systems with a curved array transducer.

RESULTS

In all 3 cases, we noted mild cardiac volume overload without fetal hydrops.

CONCLUSIONS

We speculate that the fetus with ADV and a restrictive alternative umbilical venous pathway may have a more benign clinical course than fetuses previously reported with unrestricted alternative pathways.

The fetal venous system, Part II: ultrasound evaluation of the fetus with congenital venous system malformation or developing circulatory compromise

The human fetal venous system is well-recognized as a target for investigation in cases of circulatory compromise, and a broad spectrum of malformations affecting this system has been described. In Part I of this review, we described the normal embryology, anatomy and physiology of this system, essential to the understanding of structural anomalies and the sequential changes encountered in intrauterine growth restriction and other developmental disorders. In Part II we review the etiology and sonographic appearance of malformations of the human fetal venous system, discuss the pathophysiology of the system and describe venous Doppler investigation in the fetus with circulatory compromise.

Umbilical vein anomaly in fetuses with Down syndrome

OBJECTIVE

To describe the prevalence of abnormal umbilical vein (UV) anatomy in fetuses with Down syndrome.

METHODS

This was a retrospective survey covering a 24-month period of fetuses with a genetic diagnosis of Down syndrome following a routine early second-trimester (12-16-week) detailed fetal anomaly scan at a single academic tertiary referral center. In our unit this exam includes fetal umbilicoportal venous system evaluation.

RESULTS

During the study period, 37 fetuses were diagnosed with Down syndrome and had a detailed early anatomy scan. In four (11%) the detailed early anomaly scan revealed that the UV was connected to the hepatic portion of the inferior vena cava (IVC) at a position lower than its usual site. Their average gestational age at diagnosis was 13 + 6 (range, 11 + 6 to 15 + 2) weeks. Three of the four fetuses had a nuchal translucency thickness of 3-4 mm. In one fetus there was an additional finding of significant tricuspid regurgitation and the one with normal nuchal translucency thickness had an atrioventricular septal defect (atrioventricular canal) and umbilical cord hernia. During the same period three of 2500 (0.12%) fetuses with normal karyotype demonstrated similar anomalous insertion of the UV into the IVC, creating a portocaval shunt which had normal ductus venosus-like Doppler flow in all three cases. The odds ratio for abnormal umbilicoportal venous system in fetuses with Down syndrome compared with the normal population was 107.4 (95% CI, 19.2-637.1).

CONCLUSIONS

Fetuses with Down syndrome demonstrate an increased prevalence of abnormal connection of the UV to the IVC.

Prenatal diagnosis of congenital agenesis of the fetal portal venous system

OBJECTIVE

To describe the prenatal diagnosis and review our experience of fetal congenital agenesis of the portal venous system (CAPVS) and to review the current literature on this poorly documented vascular malformation.

METHODS

This was a retrospective survey covering the 12-year period between 1996 and 2008. The database of a single, large, ultrasonographic tertiary academic referral center in Israel was analyzed and cases with a prenatal diagnosis of CAPVS were identified. All fetuses underwent detailed biometric and structural ultrasound examinations and a precise anatomical description of the fetal umbilical, portal and hepatic venous system was noted, as well as the presence of aberrant vessels, shunt location and the presence or absence of the DV. Results of fetal echocardiography, karyotyping and toxoplasma, rubella, cytomegalovirus and herpes evaluations were determined. Medical records were evaluated. Diagnosis was confirmed by pathology, postmortem venography or neonatal ultrasound or venography. Liveborns were examined by a certified neonatologist and long-term follow-up from pediatric gastroenterology units was determined.

RESULTS

Nine cases with CAPVS were studied. In all cases an aberrant umbilical-portal vein was the primary indication for detailed portal system evaluation. Five fetuses demonstrated total CAPVS (Type I) and four showed partial agenesis of the portal vein (Type II). Among the five Type I fetuses, there was a shunt from the umbilical vein to the inferior vena cava in three (60%), to the right atrium in one and to the coronary sinus in one. In this group, in only one case could we delineate a common confluence between the splenic vein and the superior mesenteric vein shunting to the inferior vena cava. In four cases termination of pregnancy was performed due to additional findings: one case with hydrothorax, ascites and mitral atresia, one with cleft lip/palate and one with trisomy 21. One case had no additional anomalies, but the parents elected to terminate the pregnancy. All four of the Type II fetuses had a portosystemic shunt: in two cases to the right atrium, in one to the iliac vein and in one to the right hepatic vein. In three, the shunt resolved spontaneously. In only one case was abnormal liver function present over a follow-up period of 2-10 years.

CONCLUSION

CAPVS can be detected prenatally. An abnormal course of the umbilical vein necessitates prompt sonographic evaluation of the umbilical-portal venous system and meticulous investigation for additional anomalies. Complete CAPVS may be associated with remote clinical consequences of which the parents should be informed. Partial CAPVS has a favorable prognosis.

Congenital portosystemic shunts and AMPLATZER vascular plug occlusion in newborns

Congenital portosystemic shunts (CPSs) may cause myriad manifestations. They can be detected prenatally, in infancy, or later. They may involute, cause acute symptoms, or remain unrecognized and cause chronic disease. As CPSs can require treatment, early diagnosis allows close monitoring. In symptomatic patients, interventional catheterization embolization of CPSs can be undertaken at any age.

Three-dimensional ultrasonographic depiction of fetal abdominal blood vessels

OBJECTIVE

The purpose of this study was to identify fetal abdominal vasculature with 3-dimensional (3D) ultrasonography and to describe a systematic method for analysis of volume data sets.

METHODS

Three-dimensional volumes of the fetal abdomen were acquired prospectively in 30 patients between 15 and 34 weeks' gestation with color Doppler, high-definition (HD) flow, power Doppler, and B-flow imaging. All volumes were analyzed offline by 2 examiners separately. The feasibility of identifying the fetal abdominal blood vessels was analyzed. A standardized approach was applied to identify specific vessels by correlating the images with known anatomic landmarks.

RESULTS

The volumes were rotated into an anatomic orientation in the multiplanar mode, and then the vessels were identified in the following order: aorta (30 of 30), celiac trunk (29 of 30), superior mesenteric vein (28 of 30 and 26 of 30 for readers 1 and 2, respectively), superior mesenteric artery (29 of 30), left renal artery (25 of 30 and 26 of 30), right renal artery (27 of 30), common iliac arteries (30 of 30), umbilical arteries (26 of 27), external iliac arteries (20 of 22), umbilical vein (29 of 30), ductus venosus (30 of 30), hepatic vein (29 of 30), right portal vein (29 of 30), inferior vena cava (28 of 30), adrenal artery (2 of 30), hepatic artery (24 of 30 and 23 of 30), splenic artery (24 of 30 and 23 of 30), gastric artery (14 of 30 and 9 of 30), splenic vein (19 of 30 and 15 of 30), and renal vein (1 of 30). A step-by-step systematic approach to identify the abdominal vasculature from the ultrasonographic volume data set was developed.

CONCLUSIONS

Fetal abdominal vessels can be easily visualized when a systematic analysis is performed on 3D data set volumes. Visualization of the vessels was optimal when volumes were acquired with HD flow imaging.