1. Fetal cerebral blood flow and volume
Juriy Wladimiroff, MD, PhD
FRCOG, FCYNGOF, FEBCOG, FISUOG, FAIUM, FAOGU, Dr h.c.

2. l Fetal growth restriction Fetal undernutrition Fetal hypoxaemia
Restricted liver growth
Protected brain growth
Hemodynamic redistribution
e.g. brain sparing
US:
Liver volume
Brain volume
Brain/liver vol ratio!
Umbilical venous volume flow l

3. COLOUR FLOW IMAGE OF MIDDLE CEREBRAL ARTERY

6. MIDDLE CERBRAL ARTERY: NORMAL WAVEFORM

7. MIDDLE CEREBRAL ART.: ABNORMAL WAVEFORM: BRAIN SPARING

8. Fetal middle cerebral artery Pulsatility Index

9. Fetal anterior/middle/posterior cerebral art PI

10. Middle cerebral art. mean blood flow velocity cm/sec

11. Scherjon et al; Pediatrics, 2005; 205:385-391 (ISUOG;Brezinka,2011)

13. Umbilical venous cross-sectional area

14. Umbilical venous volume flow (ml/min) = 0
Umbilical venous volume flow (ml/min) = 0.06 x (time averaged velocity (mm/s) x cross-sectional area (mm2) )

15. Umbilical venous blood flow (ml/min)

16. Umbilical venous blood flow/kg fetus

17. Umbilical artery Pulsatility Index
Mean SD
SGA with normal
volume flow/kg fetus  0.9
SGA with reduced
volume flow/kg fetus  2.2
p-value <0.05

18. BRAIN /LIVER VOLUME RATIO
WAT HAPPENS TO THE BRAIN TO LIVER VOLUME RATIO IN THE PRESENCE OF UTERO-PLACENTAL INSUFFIENCY AS EXPRESSED BY UMBILICAL VENOUS BLOOD FLOW ?

20. Brain volume measured with 3DUS
Glabella
Opisthion
‘Vocal mode’

21. Fetal Liver volume (ml)

22. Normal fetal brain volume relative to gestational age age
BV(ml)= 1/12  x (HC / )3

23. Estimated brain/liver volume ratio relative to umbilical venous volume flow/ kg fetal weight

24. In the presence of fetal growth restriction umbilical venous volume flow is significantly reduced
When taking into account umbilical venous volume flow data standardised for fetal weight, reduced values are associated with raised umbilical artery pulsatility index values indicating raised fetal placental downstream impedance due to progressive fetal hypoxaemia
In fetal growth restriction, fetal brain/liver volume ratio starts to increase at umbilical venous volume flow levels of as low as ml/l when standardised for fetal weight

26. Management of Rhesus disease

27. Mari et al NEJM 2001
Moving from amnio + Liley chart to fetal blood typing from maternal blood and non-invasive MCA Doppler PSV has revolutionized the management of Rhesus disease
Amniocentesis almost never performed; cordocentesis only as a prelude to transfusion: Far fewer invasive tests 27

28. Fetal hemodynamic adaptive changes related to intrauterine growth
Fetal hemodynamic adaptive changes related to intrauterine growth. The Generation R study
Depts Obstetrics & Gynaecology, Division of Obstetrics & Perinatal Medicine; Epidemiology & Biostatistics; Pediatrics, Erasmus university Medical School.
Authors:
BO Verburg
VWV Jaddoe
JW Wladimiroff
A Hofman
JCM Witteman
EAP Steegers

29. Umbilical venous cross-sectional area

30. Umbilical venous blood flow (ml/min)

31. Umbilical venous blood flow/kg fetus

33. Brain volume measured with 3DUS
Glabella
Opisthion
‘Vocal mode’

35. Conclusions
Fetal growth restriction is characterised by centralisation of the circulation with preferential blood supply/oxygenation of fetal brain,( heart and adrenals);
Fetal cerebral bloodflow: increased diastolic blood flow indicates fetal brain sparing; increased systolic blood flow indicates fetal anaemia;
Reduction of umbilical venous bloodflow to 60-80ml/kg/min is associated with an increase in fetal brain/liver volume ratio

36. Umbilical artery Pulsatility Index
Mean SD
SGA with normal
volume flow/kg fetus  0.9
SGA with reduced
volume flow/kg fetus  2.2
p-value <0.05

37. Umbilical venous TA velocity (mm/s)

38. Umbilical venous area (mm2)

39. Fetal descending aorta PI

40. Estimated brain/liver volume ratio relative to umbilical venous volume flow/ kg fetal weight

41. CONCLUSIONS
Normal umbilical venous volume flow increases approximately 7-fold during the second half of pregnancy
A gestational age related decrease exists for umbilical venous volume flow per kg fetus, that is standardised for fetal weight

43. Blood supply to the fetal brain