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Background: The likelihood of a patient being preload responsive—a state where the cardiac output or stroke volume (SV) increases significantly in response to preload—depends on both cardiac filling and function. This relationship is described by the canonical Frank-Starling curve. Research Question : We hypothesize that a novel method for phenotyping hypoperfused patients (ie, the "Doppler Starling curve") using synchronously measured jugular venous Doppler as a marker of central venous pressure (CVP) and corrected flow time of the carotid artery (ccFT) as a surrogate for SV will refine the pretest probability of preload responsiveness/unresponsiveness. Study Design and Methods: We retrospectively analyzed a prospectively collected convenience sample of hypoperfused adult emergency department (ED) patients. Doppler measurements were obtained before and during a preload challenge using a wireless, wearable Doppler ultrasound system. Based on internal jugular and carotid artery Doppler surrogates of CVP and SV, respectively, we placed hemodynamic assessments into quadrants (Qx) prior to preload augmentation: low CVP with normal SV (Q1), high CVP and normal SV (Q2), low CVP and low SV (Q3) and high CVP and low SV (Q4). The proportion of preload responsive and unresponsive assessments in each quadrant was calculated based on the maximal change in ccFT (ccFTΔ) during either a passive leg raise or rapid fluid challenge. Results: We analyzed 41 patients (68 hemodynamic assessments) between February and April 2021. The prevalence of each phenotype was: 15 (22%) in Q1, 8 (12%) in Q2, 39 (57%) in Q3, and 6 (9%) in Q4. Preload unresponsiveness rates were: Q1, 20%; Q2, 50%; Q3, 33%, and Q4, 67%. Interpretation: Even fluid naïve ED patients with sonographic estimates of low CVP have high rates of fluid unresponsiveness, making dynamic testing valuable to prevent ineffective IVF administration. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion Ultrasonography as a guide for intravenous (IV) fluid therapy is increasingly accepted within the spheres of acute care. Initial investigations and protocols often focused on measures of arterial flow as an objective approach for personalising organ ‘perfusion.’ More recently, and with literature associating excessive IV fluid with adverse outcomes, venous ultrasound as a measure of organ ‘congestion’ is taking hold. Yet, arterial (i.e., ‘perfusion’) and venous (i.e., ‘congestion’) Doppler ultrasound measures are often performed separately and can be time‐consuming, especially for novices.We report a case, wherein venous and arterial Doppler were simultaneously measured using a wireless, wearable ultrasound as a means to optimise flow without congestion.Before IV volume expansion, the patient had Doppler measures consistent with low central venous pressure (CVP) and stroke volume (SV). Following IV volume expansion, venous Doppler remained the same; however, carotid corrected flow time (ccFT) increased significantly.A framework for venous‐arterial Doppler enhanced resuscitation (VADER) can be used to guide IV volume in patients at risk for venous congestion. [ABSTRACT FROM AUTHOR]

Background: Emergency haemodialysis (HD) is a therapeutic procedure performed in serious clinical situations. This study investigated venous Doppler ultrasound parameters for predicting emergency HD in patients on routine HD treatment for end-stage renal disease in the emergency department (ED). Method: Adult patients on a routine HD program in a tertiary care ED between April and December 2022 were enrolled in the study. Inferior vena cava, hepatic, and portal vein flow parameters and the venous excess ultrasound (VExUS) score calculated from these parameters were noted in order to predict emergency HD indications. Hyperkalaemia, hypervolemia, missing more than one session, uremic findings, and metabolic acidosis were regarded as emergency HD indications. Results: One hundred twenty-nine venous ultrasound examinations were performed on 43 patients with routine HD during the study period. The rate of emergency HD was 30.2%. The most common indication of it was hypervolemia (76.9%), followed by missing more than one session (23.1%). Only the portal vein had an AUC value of 0.714, with a sensitivity of 61.5% and specificity of 83.3% for predicting emergency HD. Other parameters including the IVC, hepatic vein, and VExUS score were of no diagnostic value. Conclusion: The findings of this study show that only the portal vein Doppler flow parameter has very limited diagnostic value for emergency HD in patients on a routine HD program in the ED. This study can serve as a guide to further research. [ABSTRACT FROM AUTHOR]

The accurate identification of perforator veins (PV) in asymptomatic veins that do not meet the criteria established by venous Doppler (VD) is a complex challenge, considered the gold standard in diagnosis, and is operator-dependent. This study explored the potential of dual infrared–visual thermography (IRVT) to identify PV in 99 patients aged 29 to 80 years. IRVT was conducted using a high-definition hyperspectral visual–infrared sensor. The temperature difference (ΔT) between maximum temperature (Tmax) and minimum temperature (Tmin) within the region of interest (ROI) served as an indicator for assessing vascular dysfunction severity. Comparative analysis was performed with VD results obtained using a Doppler ultrasound unit equipped with a 7.5 MHz linear transducer. Significant statistical differences (p < 0.05) in ΔT (Tmax−Tmin) were observed among PV sites categorized by reflux severity: no reflux (ΔT = 1.2 °C), mild reflux (ΔT = 1.8 °C), moderate reflux (ΔT = 2.9 °C), and severe reflux (ΔT = 3.6 °C). This study concludes that IRVT effectively distinguishes varying degrees of vascular reflux severity. IRVT shows promise as a non-invasive, radiation-free tool to enhance PV identification, especially in challenging cases, potentially improving patient outcomes and healthcare management. Further research is required to validate and refine its diagnostic utility. [ABSTRACT FROM AUTHOR]

Abstract Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid ‘dose–response’ curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., ‘fluid responsive’). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., ‘fluid unresponsive’) with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a ‘Doppler Starling curve’ framework; implications for IV fluid dosing are discussed.

Providing intravenous (IV) fluids to a patient with signs or symptoms of hypoperfusion is common. However, evaluating the IV fluid 'dose–response' curve of the heart is elusive. Two patients were studied in the emergency department with a wireless, wearable Doppler ultrasound system. Change in the common carotid arterial and internal jugular Doppler spectrograms were simultaneously obtained as surrogates of left ventricular stroke volume (SV) and central venous pressure (CVP), respectively. Both patients initially had low CVP jugular venous Doppler spectrograms. With preload augmentation, only one patient had arterial Doppler measures indicative of significant SV augmentation (i.e., 'fluid responsive'). The other patient manifested diminishing arterial response, suggesting depressed SV (i.e., 'fluid unresponsive') with evidence of ventricular asynchrony. In this short communication, we describe how a wireless, wearable Doppler ultrasound simultaneously tracks surrogates of cardiac preload and output within a 'Doppler Starling curve' framework; implications for IV fluid dosing are discussed. [ABSTRACT FROM AUTHOR]

The accurate identification of perforator veins (PV) in asymptomatic veins that do not meet the criteria established by venous Doppler (VD) is a complex challenge, considered the gold standard in diagnosis, and is operator-dependent. This study explored the potential of dual infrared–visual thermography (IRVT) to identify PV in 99 patients aged 29 to 80 years. IRVT was conducted using a high-definition hyperspectral visual–infrared sensor. The temperature difference (ΔT) between maximum temperature (Tmax) and minimum temperature (Tmin) within the region of interest (ROI) served as an indicator for assessing vascular dysfunction severity. Comparative analysis was performed with VD results obtained using a Doppler ultrasound unit equipped with a 7.5 MHz linear transducer. Significant statistical differences (p < 0.05) in ΔT (Tmax−Tmin) were observed among PV sites categorized by reflux severity: no reflux (ΔT = 1.2 °C), mild reflux (ΔT = 1.8 °C), moderate reflux (ΔT = 2.9 °C), and severe reflux (ΔT = 3.6 °C). This study concludes that IRVT effectively distinguishes varying degrees of vascular reflux severity. IRVT shows promise as a non-invasive, radiation-free tool to enhance PV identification, especially in challenging cases, potentially improving patient outcomes and healthcare management. Further research is required to validate and refine its diagnostic utility.

Abstract Conventional parameters for assessment of fluid status suffer from several limitations. IVC maybe chronically dilated in patients with pulmonary hypertension. Portal vein Doppler offers an additional data point to assess the severity of venous congestion as well as monitor the efficacy of decongestive therapy.

Point of care ultrasonography can be a valuable adjunct to conventional physical examination in patients with hyponatremia that aids in clinical decision making. It can address the shortcomings of traditional volume status assessment such as the inherent low sensitivity of ‘classic’ signs such as lower extremity edema. Herein, we present a case of a 35-year-old woman where discrepant clinical findings led to confusion in the accurate assessment of volume status but addition of point of care ultrasonography helped to guide the therapy.

In patients with heart failure and cardiorenal syndrome, lingering congestion is associated with worse outcomes. As such, titrating diuretic or ultrafiltration therapy based on objective assessment of volume status plays a crucial role in the management of these patients. Conventional physical examination findings and parameters such as daily weight measurement are not always reliable in this setting. Recently, point of care ultrasonography (POCUS) has emerged as an attractive enhancement to bedside clinical examination in assessing fluid volume status. Specifically, Doppler ultrasound of the major abdominal veins gives additional information about end-organ congestion when used in conjunction with inferior vena cava ultrasound. Moreover, these Doppler waveforms can be monitored in real time to gauge the efficacy of decongestive therapy. Herein, we present a case that illustrates the utility of POCUS in the management of a patient with heart failure exacerbation.

Varicose veins are abnormally dilated, tortuous and elongated veins that occur in the lower limbs. The patients usually present to the surgical outpatient department with various clinical presentations such as, dilated veins, venous ulcers over the legs, pigmentation of the skin and lipodermatosclerosis to name a few. Venous doppler is a very important investigation that must be done in a cases of varicose veins. The surgical treatment involves sapheno-femoral junction flush ligation with stripping of the varicose vein. Several other modalities are also available today such as, sclerotherapy and endovascular laser ablation (EVLA). The objective of this study was to determine the clinical profile of the patients who presented with varicose veins and to determine the treatment that was offered to them to treat the varicose veins. This study was carried out from September 2015 to August 2018. A total of 62 patients were studied. The statistics were analysed using SPSS package 20.0. Ethical clearance was obtained from the institutional ethics committee. The presence of dilated veins was the most common complaint with which patients presented to the surgical outpatient department. The most common surgical procedure that was performed was the sapheno-femoral junction flush ligation with stripping of the varicose vein. This study shows the importance of diagnosing a case of varicose veins and to determine as early as possible the treatment modality that should be offered to the patient. [ABSTRACT FROM AUTHOR]

Background: Fetal superior vena cava (SVC) is essentially the single vessel returning blood from the upper body to the heart. With approximately 80-85% of SVC blood flow representing cerebral venous return, its interrogation may provide clinically relevant information about fetal brain circulation. However, normal reference values for fetal SVC Doppler velocities and pulsatility index are lacking. Our aim was to establish longitudinal reference intervals for blood flow velocities and pulsatility index of the SVC during the second half of pregnancy.Methods: This was a prospective study of low-risk singleton pregnancies. Serial Doppler examinations were performed approximately every 4 weeks to obtain fetal SVC blood velocity waveforms during 20-41 weeks. Peak systolic (S) velocity, diastolic (D) velocity, time-averaged maximum velocity (TAMxV), time-averaged intensity-weighted mean velocity (TAMeanV), and end-diastolic velocity during atrial contraction (A-velocity) were measured. Pulsatility index for vein (PIV) was calculated.Results: SVC blood flow velocities were successfully recorded in the 134 fetuses yielding 510 sets of observations. The velocities increased significantly with advancing gestation: mean S-velocity increased from 24.0 to 39.8 cm/s, D-velocity from 13.0 to 19.0 cm/s, and A-velocity from 4.8 to 7.1 cm/s. Mean TAMxV increased from 12.7 to 23.1 cm/s, and TAMeanV from 6.9 to 11.2 cm/s. The PIV remained stable at 1.5 throughout the second half of pregnancy.Conclusions: Longitudinal reference intervals of SVC blood flow velocities and PIV were established for the second half of pregnancy. The SVC velocities increased with advancing gestation, while the PIV remained stable from 20 weeks to term. [ABSTRACT FROM AUTHOR]

Conventional parameters for assessment of fluid status suffer from several limitations. IVC maybe chronically dilated in patients with pulmonary hypertension. Portal vein Doppler offers an additional data point to assess the severity of venous congestion as well as monitor the efficacy of decongestive therapy. Conventional parameters for the assessment of fluid status suffer from several limitations. IVC may be chronically dilated in patients with pulmonary hypertension. Portal vein Doppler offers an additional data point to assess the severity of venous congestion and monitor the efficacy of decongestive therapy. [ABSTRACT FROM AUTHOR]

The present meta-analysis aims to compare renal arterial and venous Doppler parameters in women with preeclampsia and healthy pregnant controls. Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and Google Scholar databases were systematically searched from inception to December 04, 2019. All observational studies reporting renal resistive index, pulsatility index, renal interlobar vein impedance, or pulse transit time among preeclamptic and healthy pregnant women were held eligible. Subgroup analysis was conducted on the basis of disease onset and side of measurement. Both pair-wise and network meta-analysis were performed using Review Manager 5.3 and R-3.4.3 software. Fourteen studies were included, with a total of 1118 women. No difference of renal resistive (MD: 0.00, 95% CI: [-0.03, 0.04]) and pulsatility index (MD: -0.01, 95% CI: [-0.14, 0.12]) was evident between the two groups. Renal interlobar vein impedance was estimated to be significantly higher in preeclampsia (MD: 0.07, 95% CI: [0.06, 0.09]), while venous pulse transit time was significantly lower (MD: -0.10, 95% CI: [-0.14, -0.05]) in women with the disease. Subgroup analysis indicated that early-onset preeclampsia was associated with significantly elevated renal interlobar vein impedance and lower venous pulse transit time than late-onset disease. The outcomes of the present meta-analysis suggest that preeclampsia is characterized by venous hemodynamic dysfunction as it is associated with significantly elevated renal interlobar vein impedance and shorter venous pulse transit time. Future large-scale prospective studies should introduce cutoff values and determine the optimal timing of measurement in order to achieve optimal predictive accuracy. [ABSTRACT FROM AUTHOR]

Objective: To assess the correlation of Myocardial Performance Index (MPI), Doppler ultrasound indices of fetal blood vessels with perinatal mortality and early neonatal morbidity in small-for-gestational age (SGA) fetuses. Materials and Methods: The cross-sectional study of singleton pregnancies with small for gestational age fetuses with perinatal mortality and early neonatal morbidity was conducted from March 1st to November 30th, 2014. Forty-nine cases of singleton pregnancies with SGA fetuses were enrolled by excluding chromosome abnormality, major organ anomaly or intrauterine infection. MPI, Doppler ultrasonography of umbilical artery, middle cerebral artery, aortic isthmus, ductus venosus and umbilical vein were performed within 48 hours before delivery. The Z-scores were calculated for Doppler indices. The delivery method and the indication of delivery, data regarding perinatal mortality, bronchopulmonary dysplasia (BPD), interventricular hemorrhage (IVH) and necrotizing enterocolitis (NEC) were recorded. The correlation and multiple logistic regression analyses was used to find the significant factors of perinatal mortality and early neonatal morbidity in SGA fetuses. Results: Total 38 pregnant women and newborns were analyzed. No perinatal mortality was detected but found some of early neonatal morbidity. 6 newborns needed to admit in NICU (15.8%), 3 of which had BPD (7.9%). Neither IVH nor NEC was detected. This study did not demonstrate the correlation between MPI, all Doppler parameters after dichotomous branching and early neonatal morbidity, with individual adjusted R2 = -0.027 (p-value= 0.951) for UA S/D ratio ≥ 95th percentile, -0.005 (p-value= 0.819) for UA PI ≥ 95th percentile, 0.091 (p-value=0.368) for cerebroplacental ratio ≤ 1.08, 0.088 (p-value= 0.996) for aortic isthmus flow index ≤ 5th percentile, 0.160 (p-value= 0.058) for MPI ≥ 95th percentile. Only, the gestational age (GA <38 wks) was the only significant factor associated with early neonatal morbidity with adjusted R2 of 0.620 (p-value <0.05, Odd ratios 7.0, 95%CI: 0.61-79.87). Conclusion: There was no significant correlation between perinatal mortality and early neonatal morbidity in small-for-gestational age (SGA) fetuses with Doppler ultrasound parameters in terms of MPI, UA S/D ratio, UA pulsatility index, MCA pulsatility index, DV waveform, aortic isthmus flow index and UV waveform in SGA fetuses. Gestation age was the most significant associated factor with early neonatal morbidity in SGA fetuses. However, no conclusion could be drawn regarding the correlation of perinatal mortality with MPI and Doppler ultrasound parameters due the lack of fetal and neonatal death. [ABSTRACT FROM AUTHOR]

This review summarizes current knowledge from experimental and clinical studies on renal function and venous hemodynamics in normal pregnancy, in gestational hypertension (GH) and in two types of preeclampsia: placental or early-onset preeclampsia (EPE) and maternal or late-onset (LPE) preeclampsia, presenting at

Mondor’s disease is a rare condition characterised by superficial thrombophlebitis of subcutaneous veins, most commonly over the anterior chest wall. Penile Mondor’s disease is rarer, arising out of thrombophlebitis of the penile veins. It typically involves the dorsal vein of the penis and presents with a cord-like indurated lesion with a beaded feel, palpable along the length of the involved vein. Though penile Mondor’s disease involving the dorsal vein of the penis has been reported by many authors, we report a peculiar case of penile Mondor’s disease in a 26-year-old sexually active man with thrombophlebitis of the circumflex vein of the penis with sparing of the dorsal vein. Diagnosis was confirmed on Doppler ultrasonography of the penile venous system. Despite exhaustive history taking, no cause could be elicited. The lesion completely subsided within three days with daily local hot fomentation. We propose the term ‘atypical penile Mondor’s disease’ for such a case. [ABSTRACT FROM PUBLISHER]

ABSTRACT Objectives To investigate fetal venous Doppler measurements in monochorionic twin pregnancies complicated by placental insufficiency and the relationship between fetal venous flow and acidemia at birth or intrauterine fetal death. Methods This was a prospective study of 18 monochorionic twin pregnancies with placental insufficiency. Inclusion criteria were monochorionic-diamniotic twin pregnancy, abnormal umbilical artery ( UA) Doppler indices, intact membranes and absence of fetal congenital abnormalities. Cases of twin-to-twin transfusion syndrome were excluded. The following Doppler measurements were studied: UA pulsatility index ( PI), ductus venosus PI, middle cerebral artery PI and peak systolic velocity, intra-abdominal umbilical vein ( UV) time-averaged maximum velocity ( TAMXV) and left portal vein ( LPV) TAMXV. Doppler parameters were transformed into Z- scores ( SD values from the mean) or multiples of the median according to normative references. Results UA pH < 7.20 occurred in nine (25.0%) neonates, pH < 7.15 in four (11.1%) and intrauterine death in four (11.1%) fetuses. The UV-TAMXV and LPV-TAMXV Z- scores were significantly lower in the group with pH < 7.20 or intrauterine fetal death (-1.79 vs - 1.22, P = 0.006 and -2.26 vs - 1.13, P = 0.04, respectively). In cases with pH < 7.15 or intrauterine fetal death, UV pulsations were more frequent (50.0% vs 10.7%, P = 0.03) and UV-TAMXV Z- score was significantly lower (-1.89 vs - 1.26, P = 0.003). Mixed effects logistic regression analysis, accounting for the paired nature of the outcomes for the two twins in each pregnancy, demonstrated that the UV-TAMXV Z- score significantly predicted UA pH at birth < 7.20 or intrauterine fetal death. The Doppler parameter that independently predicted pH < 7.15 or intrauterine fetal death was presence of pulsation in the UV. Conclusion UV Doppler parameters may predict acidemia at birth or intrauterine fetal death in monochorionic twins complicated by placental insufficiency. Copyright © 2013 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Abstract: Delivery of a healthy full term baby following an uneventful antenatal period occurs in the majority of pregnancies. These are classified as a low-risk pregnancy group. There are, however, some pregnancies that are complicated due to maternal or fetal disease that can increase the risk of perinatal morbidity and mortality. This is classified as a high-risk group. The aim of fetal surveillance is to identify these threatened fetuses with the prospect of altering the timing of delivery to prevent the worst outcome, stillbirth. This article looks at the tools available to assess antenatal fetal health in all pregnancies and their ability to identify the at-risk pregnancies that require extra surveillance to improve outcomes. This article does not address fetal surveillance during labour. [Copyright &y& Elsevier]

Summary: Sonographic evaluation of the fetal venous system in normal and abnormal conditions has drawn increasing interest in recent years. Whereas the assessment of the fetal heart and the related arteries is standardized using well-defined planes, the fetal venous system is still lacking a systematic approach. In this article we present a novel sonographic algorithm for a systematic examination of the fetal venous system using six planes of transverse and oblique views of the fetal abdomen and chest. These planes, using two-dimensional and color Doppler, enable a targeted demonstration of the typical veins to include the umbilical vein, ductus venosus, portal veins, hepatic veins, inferior vena cava, azygos vein, pulmonary veins, coronary sinus, superior vena cava and brachiocephalic vein. We postulate that integrating such a sequential stepwise algorithm for the evaluation of the venous system into targeted fetal cardiac imaging may improve the detection of isolated and combined anomalies of the fetal systemic and pulmonary veins. [Copyright &y& Elsevier]

Summary: Doppler evaluation of the placenta and fetal cardiovascular system is one of the primary surveillance tools in prenatal medicine. By assessing uterine and umbilical arteries, placental development can be documented. This is useful for the prediction of hypertensive maternal disorders and placental dysfunction and fetal growth failure. The umbilical artery flow velocity waveform provides an estimate of villous vascular occlusion in the fetal compartment of the placenta. Middle cerebral artery Doppler is important in studying fetal responses to abnormal oxygenation and fetal anemia. Precordial venous Doppler gives insight into the cardiac effects of many conditions such as fetal growth restriction, twin–twin transfusion syndrome and fetal arrhythmia. Further quantification of these effects requires cardiac Doppler to quantify diastolic and systolic function as well as global myocardial performance. This article reviews important characteristics of arterial and venous Doppler waveform analysis, individual vascular beds and their clinical application in fetal evaluation. [ABSTRACT FROM AUTHOR]

The article analyzes aspects of the ultrasound evaluation of the malformations in the human fetal venous system. It states that an abnormal development in the system can be based from any of its embryonic systems including umbilical and cardinal systems. It presents several abnormalities in the system which include heterotaxy syndromes and primary failure to create critical anastomoses. It concludes that fetal system anomalies can be diagnosed by recognition of their sonographic appearance.

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Abstract: Most pregnancies, irrespective of risk factors, lead to the delivery of a healthy baby. Some fetuses are at risk of developing complications that may result in future disease, handicap or death. Fetal surveillance should be instituted, attempting to identify fetuses at risk, to reduce the chances of complications. Traditionally, obstetricians have classified pregnancies into ‘low-risk’ or ‘high-risk’, and applied surveillance tools to the latter group. Most stillbirths occur in low-risk women. We evaluate the tools available to assess fetal health in both groups during the antenatal period, evaluate their ability to detect a fetus at risk, and ascertain if they result in improved outcome. [Copyright &y& Elsevier]

The article examines the performance of nonstress testing, computerized fetal heart rate analysis, biophysical profile scoring and arterial and venous Doppler ultrasound investigation in the prediction of acid-base status in fetal growth restriction. The study involved a selected population of fetuses with severe placental insufficiency. It is pointed out that growth-restricted fetuses require antenatal testing using multiple surveillance modalities to enhance prediction of birth pH.

Abstract: Intra uterine growth retardation is a major cause of perinatal morbidity and mortality. These are due to prolonged intra uterine hypoxia and complications from subsequent induced prematurity. Fetal arterial doppler measurements, and more recently venous Doppler measurements, help choosing the ideal moment for delivering these fragile fetuses. Nevertheless, venous doppler measurements should be combined to other monitoring tools, used longitudinally and only when very preterm birth is expected. [Copyright &y& Elsevier]

Abstract: Objective: To analyze the effects of uterine contractions on ductus venosus (DV) pulsatility during the first stage of labor. Methods: Twenty healthy women were examined. Measurements were taken at three stages of cervical dilatation (<4 cm, 4–7 cm and ≥8 cm) during and between contractions. Peak velocity during ventricular systole (S) and atrial contraction (A), pulsatility index for veins (DV PIV), ductus venosus index (DVI) and the S/A ratio were measured. Results: The DV was observed successfully in 16 cases. The mean S velocity did not change significantly (64 cm/s during and 65 cm/s between contractions). The mean A velocity decreased significantly from 35 cm/s measured between contractions to 29 cm/s during contractions (P <0.0001). The mean DV PIV and DVI were significantly higher during contractions (0.72 and 0.55) than between contractions (0.57 and 0.45) (P <0.0001). There were no significant differences in means between stages of cervical dilatation. Conclusion: Significant differences during and between uterine contractions can be observed in DV pulsatility during normal labor. [Copyright &y& Elsevier]

Objective To assess the impact of isolated lesions of the fetal right heart on ductus venosus (D V) blood flow profiles. Methods Retrospective evaluation of DV blood flow profiles in 83 fetuses with isolated right-sided cardiac lesions. Cases were divided into two groups. Group A had right-sided cardiac lesions associated with a large ventricular septal defect that equalized interventricular pressures (double outlet right ventricle (n = 12), tetralogy of Fallot (n = 19), pulmonary atresia (n = 5)). Group B had right-sided cardiac lesions with obstruction of the inflow (tricuspid atresia with ventricular septal defect (n = 14)) or obstruction of the outflow with intact ventricular septum (Ebstein's anomaly (n = 13), pulmonary stenosis (n = 13) and pulmonary atresia (n = 7)). Comparisons were made with 585 uneventful singleton pregnancies and previously published normative values. Results Fetuses in Group B had significantly higher rates of abnormal DV flow profiles compared to Group A and controls (P < 0.01). Conversely, there were no significant differences concerning DV parameters between fetuses in Group A and controls. Despite these different DV flow characteristics, there were no significant differences concerning signs of cardiac failure and/or survival to the perinatal period between the two groups. Conclusions Right-sided cardiac lesions with obstruction of the inflow or outflow with intact ventricular septum are significantly associated with abnormally high pulsatilities in the DV and may even cause a reversal of flow during atrial contraction. These changes do not necessarily indicate cardiac failure, as the), are primarily attributable to the special hemodynamics of the cardiac defect. [ABSTRACT FROM AUTHOR]

Objectives: Recent observations in pediatric cardiological studies have prompted discussion on the possible role of intrauterine pulmonary venous changes in neonatal and postoperative outcome of infants with congenital heart defects. This study analyzes changes of Doppler blood flow velocity waveforms in the pulmonary veins of fetuses with different cardiac defects. Methods: Eighty fetuses (mean gestational age, 27 weeks) with prenatally diagnosed cardiac defects were classified into one of five groups: obstructed left atrium, other left ventricular outflow tract obstruction, right ventricular outflow tract obstruction, miscellaneous cardiac defects and total anomalous pulmonary venous drainage. Doppler examination of the pulmonary veins was performed and the time velocity integral (TVI), end-diastolic (A) velocity, and pulsatility index for veins (PIV) were compared with reference ranges. Results: Fetuses with infradiaphragmatic total anomalous pulmonary venous drainage showed a continuous Doppler flow pattern instead of the typical pulsatile waveform pattern. In fetuses with obstructed left atrium and restrictive foramen ovale, a reversed A-velocity and increased PIV were found. In five of the eight fetuses with left outflow tract obstruction but patent mitral valve, PIV was increased. In the other groups there were no obvious changes in Doppler parameters. Conclusions: We suggest routine examination of the pulmonary veins with pulsed Doppler ultrasound in every fetus with a prenatally diagnosed heart defect. Such Doppler parameters could be used in future as cut-offs for the recently reported in-utero atrial septostomy to decompress an obstructed left atrium. [ABSTRACT FROM AUTHOR]

Abstract: Key issues in the management of early onset fetal growth restriction (IUGR<34 weeks) are accurate diagnosis and assessment of fetal well-being to optimize timing of delivery by weighing fetal vs. neonatal risks. Cardiovascular, behavioral and fetal heart rate patterns in IUGR follow a predictable progression that corresponds with the severity of compromise. Umbilical artery (UA) Doppler primarily serves as a placental function test providing insufficient information to solely direct perinatal management. Venosus Doppler is an independent predictor of stillbirth and acidemia and needs to be examined when the UA index is elevated, especially if end-diastolic velocities are absent. Neonatal outcomes are primarily determined by gestational age and their antenatal prediction is too ineffective to guide management. Abnormal venous Doppler, biophysical profile score and mean minute variation of the fetal heart rate are strong predictors of fetal compromise therefore favoring delivery. Randomized trials indicate that delayed delivery has little effects on short-term outcome while producing a trend towards improved early childhood neurodevelopment. This stresses the need for excellent fetal surveillance techniques and their ongoing investigation through randomized management trials. [Copyright &y& Elsevier]

Objective The aim of this retrospective study was to examine the significance of severe Doppler waveform abnormalities in the ductus venosus (DV) and the umbilical vein (UV) for the prediction of adverse outcomes in very preterm growth-restricted fetuses with absent or reversed end-diastolic flow in the umbilical artery (UA) at 24–34 weeks of gestation. Methods Seventy-four fetuses with intrauterine growth restriction (IUGR) and absent or reversed end-diastolic (ARED) flow in the UA at 24–34 weeks of gestation, which were delivered before 34 weeks' gestation, were examined. Absent or reversed flow during atrial contraction (a-wave) in the DV and pulsatile flow in the UV were examined to predict severe perinatal outcomes (stillbirth, neonatal death, perinatal death, acidemia, 5 min Apgar <7, intraventricular hemorrhage and elevated nucleated red blood cell counts at delivery). Results Twelve (16.2%) perinatal deaths, of which eight were stillbirths (10.8%), and two (2.7%) neonatal deaths occurred among 74 fetuses. Logistic regression analysis confirmed that abnormal DV Doppler waveforms (R² = 0.57, P < 0.00 1) together with gestational age at delivery (R² = 0.57, P < 0.001) showed the strongest association with perinatal death, whereas only gestational age was significantly related to neonatal death (R² = 0.67, P 0.05). Abnormal DV Doppler waveforms (R² = 0.86, P < 0.001) and gestational age (R² = 0.49, P < 0.05) were strongly associated with adverse outcome (including stillbirth, perinatal death or neonatal death). Abnormal venous Doppler flow patterns performed better in the prediction of fetal or perinatal demise than did ARED flow or brain sparing. Conclusion Abnormal venous Doppler waveforms in preterm IUGR fetuses with ARED flow are strongly related to adverse fetal and perinatal outcomes before 32 weeks of gestation. The possible benefit of prolonging these pregnancies can only be evaluated in a prospective randomized study. [ABSTRACT FROM AUTHOR]

Objective: This study was undertaken to test which venous Doppler parameter offers the best prediction of acid-base status at birth in pregnancies complicated by intrauterine growth restriction (IUGR) caused by placental dysfunction. Study Design: A prospective cross-sectional Doppler study of IUGR fetuses with abnormal umbilical artery Doppler and birth weight less than the 10th percentile. Absence of atrial systolic forward velocities in the ductus venosus (DV) (DV-RAV) and umbilical vein (UV) pulsations were noted and multiple venous indices were calculated for the inferior vena cava (IVC) and DV (IVC and DV preload index, peak velocity index [PVIV] and pulsatility index [PIV] and the DV S/a ratio). Doppler indices, UV pulsations, and DV- RAV were related to an umbilical artery cord pH <7.20, and a pH <7.00 and/or base deficit greater than -13 (severe metabolic compromise) in neonates delivered by cesarean section without labor. Results: In 122 fetuses all venous Doppler indices were equally predictive of a pH <7.20, with the exception of the IVC PVIV. No Doppler index predicted severe metabolic compromise. Bayesian analysis of individual Doppler parameters showed comparable outcome prediction with the highest sensitivity for the IVC PIV (76%) and the highest specificity for DV-RAV (96%). Combined assessment of the IVC, DV, and UV provided the most accurate outcome prediction. Doppler abnormality in either vessel identified 89% of neonates with pH <7.20 (negative predictive value 92%) and 10 of 11 neonates with severe metabolic compromise. Prediction was most specific (84%) when Doppler parameters were abnormal in all 3 vessels. Conclusion: IVC, DV, and UV Doppler parameters correctly predict acid-base status in a significant proportion of IUGR neonates. Combination, rather than single vessel assessment provides the best predictive accuracy. While the choice of Doppler index can be guided by operator preference, familiarity with the examination technique of all 3 vessels is encouraged to offer the highest flexibility in clinical practice. [ABSTRACT FROM AUTHOR]

The assessment of fetal well-being by venous Doppler velocimetry, especially in cases of intrauterine growth restriction, has been growing in importance as a number of researchers have been improving their studies 1 - 5 as well as a consequence of better technologies in ultrasound equipment. Since different authors have studied the fetal blood circulation with color Doppler, initially focusing their attention on the arterial system 6 - 12 , many questions and doubts have remained without a reasonable answer, especially concerning the optimal time at which to deliver these fetuses. Among these authors, some have expressed the opinion that all biophysical methods, including the cardiotocogram, should be used before the decision of fetus delivery should be made 13 , 14 . It is possible, nowadays, to study several venous vessels, such as the ductus venosus, inferior vena cava, umbilical vein, portal vein, hepatic veins 15 , and, more recently 1 , 2 , the cerebral transverse sinus. The purpose of this review is to describe the fetal circulation, the technique and rationale behind measuring venous Dopplers and to assess the clinical applications of venous Doppler velocimetry. [ABSTRACT FROM AUTHOR]

Background Our aim was to test the hypothesis that qualitative ductus venosus and umbilical venous Doppler analysis improves prediction of critical perinatal outcomes in preterm growth-restricted fetuses with abnormal placental function. Methods Patients with suspected intrauterine growth restriction (IUGR) underwent uniform fetal assessment including umbilical artery (UA), ductus venosus (DV) and umbilical vein (UV) Doppler. Absent or reversed UA end-diastolic velocity (UA-ARED V), absence or reversal of atrial systolic blood flow velocity in the DV (DV-RA V) and pulsatile flow in the umbilical vein (P-UV) were examined for their efficacy to predict critical outcomes (stillbirth, neonatal death, perinatal death, acidemia and birth asphyxia) before 37 weeks' gestation. Results Seventeen (7.6%) stillbirths and 16 (7.1%) neonatal deaths were observed among 224 IUGR fetuses. Forty-one neonates were acidemic (19.8%) and seven (3.1%) had birth asphyxia. Logistic regression showed that UA-AREDV had the strongest association with perinatal mortality (R² = 0.49, P < 0.001), stillbirth (R² = 0.48, P < 0.001) and acidemia (R² = 0.22, P = 0.002) while neonatal death was most strongly related to DV-RAV and P-UV (R² = 0.33, P = 0.007). UA waveform analysis offered the highest sensitivity and negative predictive value and DV-RAV and P-UV had the best specificity and positive predictive values for outcome prediction. Overall, DV-RA V or P-UV offered the best prediction of acidemia and neonatal and perinatal death irrespective of the UA waveform. In fetuses with UA-ARED V, prediction of asphyxia and stillbirth was significantly enhanced by venous Doppler. Conclusion Prediction of critical perinatal outcomes is improved when venous and umbilical artery qualitative waveform analysis is combined. The incorporation of venous Doppler into fetal surveillance is therefore strongly suggested for all preterm IUG R fetuses. [ABSTRACT FROM AUTHOR]

ABSTRACT Objectives To assess the efficacy of flecainide in the intrauterine treatment of fetal supraventricular tachycardia (SVT) with 1 : 1 atrioventricular conduction. Design Twenty fetuses (21–35 weeks of gestation) with SVT ranging between 215 and 280 bpm were analyzed retrospectively. Fetuses received flecainide and digoxin as either first, second or third line therapy. Intracardiac blood flow, venous Doppler waveforms and cardiotocograms were evaluated before and after drug induced conversion to sinus rhythm. Results After initiation of combined flecainide and digoxin therapy, the median time interval until final conversion to sinus rhythm was 5 days (range, 0–14 days). The majority of fetuses (n = 15; 75%) converted to sinus rhythm within 7 days of treatment, whereas the remaining five (25%) showed initial reduction of the heart rate to 160–215 bpm over several days, with restoration of a triphasic venous blood flow pattern before late conversion within 7–14 days after initiation of flecainide treatment. One of these fetuses showed a decrease in fetal heart rate to 160–190 bpm without conversion to sinus rhythm but with resolution of hydrops. All fetuses survived. Conclusions Flecainide is safe and highly effective in the intrauterine treatment of hydropic fetuses with supraventricular tachycardia. Conversion into sinus rhythm can be expected 72 h after initiation of therapy but may take up to 14 days. Therefore therapy should be continued beyond 72 h, especially when an initial decrease of fetal heart rate is observed which may represent an early therapeutic response. [ABSTRACT FROM AUTHOR]

Objective The aim of this investigation was to assess the relationship between abnormal arterial and venous Doppler findings and perinatal outcome in fetuses with intrauterine growth restriction (IUGR). Methods Doppler velocimetry of the umbilical artery (UA), middle cerebral artery (MCA), inferior vena cava (IVC), ductus venosus (DV) and free umbilical vein was performed in 121 IUGR fetuses with a UA pulsatility index (PI) > 2SD above the gestational age mean and subsequent birth weight < 10th centile for gestational age. Groups based on the last Doppler exam were: 1 = abnormal UA-PI only (n=42, 34.7%), 2 = MCAPI>2SD below the gestational age mean (= ‘brain sparing’) in addition to abnormal UA-PI (n=29, 24.0%), 3=DV or IVC peak velocity index (PVIV)>2SD above the gestational age mean and/or pulsatile UV flow (n = 50, 41.3%). Z-scores (delta indices) were calculated for Doppler indices. Perinatal mortality, respiratory distress (RDS), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), circulatory failure and umbilical artery blood gases were recorded. Results Absence or reversal of umbilical artery end-diastolic flow was observed in 4 (9.5%) of fetuses in group 1, 10 (34.5%) fetuses in group 2 and 41 (82%) fetuses in group 3. A low middle cerebral artery pulsatility index was found in 39 (78%) fetuses in group 3. Multiple regression analysis with gestational age at delivery, delta indices and cord artery blood gas as independent parameters and individual perinatal outcomes as dependent variables was performed. In this analysis the association was strongest with gestational age for each complication. There were no significant differences in Apgar scores between groups. At delivery, ‘brain sparing’ was associated with hypoxemia and abnormal venous flows with acidemia. Perinatal mortality was highest in group 3 and stillbirth was only observed when venous flow was abnormal.... [ABSTRACT FROM AUTHOR]

Objective The objective of the current study was to evaluate fetal arterial and venous Doppler parameters in postterm pregnancies with oligohydramnios and those with normal amniotic fluid. Study Design A cross-sectional study was performed in 38 pregnancies beyond 41 weeks' gestation. Pulsed Doppler imaging was used to determine the pulsatility index (PI) for the fetal middle cerebral artery (MCA), renal artery, umbilical artery, inferior vena cava (IVC) and ductus venosus. The amniotic fluid index (AFI) was used for semiquantitive assessment of amniotic fluid volume. Oligohydramnios was defined as an AFI < 5 cm. Results Oligohydramnios was detected in 10 cases, and a normal AFI was present in 28 cases. In the presence of oligohydramnios the PI of the MCA was decreased, while the renal artery PI and the MCA PI/UA PI ratio were found to be elevated. In cases of oligohydramnios the PI in the IVC was increased but was unchanged in the ductus venosus. Conclusion Oligohydramnios in post-term pregnancies is associated with arterial redistribution of fetal blood flow typifying the brain sparing effect and with decreased resistance in the MCA and increased resistance in the fetal IVC. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the role of the venous system in cyclical mastalgia. Materials and methods: 25 healthy women and 39 women with cyclic mastalgia underwent venous Doppler examination in both pre- and postmenstrual period. Upper-outer quadrant veins of breast were evaluated. The impedance indices of both groups were compared in both the premenstrual and postmenstrual period. Results: During the premenstrual period, venous impedance indices were significantly higher in the patients with cyclic mastalgia (p =0.004) than in the control group. After the menstrual period, there was no difference in venous impedance indices between the groups. Conclusion: Excessive tissue oedema might be responsible for both a tension-mediated pain and a compression of the venous system thereby showing higher impedance than that in control group. [Copyright &y& Elsevier]

This review summarizes current knowledge from experimental and clinical studies on renal function and venous hemodynamics in normal pregnancy, in gestational hypertension (GH) and in two types of preeclampsia: placental or early-onset preeclampsia (EPE) and maternal or late-onset (LPE) preeclampsia, presenting at <34 weeks and ≥34 weeks respectively. In addition, data from maternal venous Doppler studies are summarized, showing evidence for (1) the maternal circulation functioning closer to the upper limits of capacitance than in non-pregnant conditions, with intrinsic risks for volume overload, (2) abnormal venous Doppler measurements obtainable in preeclampsia, more pronounced in EPE than LPE, however not observed in GH, and (3) abnormal venous hemodynamic function installing gradually from first to third trimester within unique pathways of general circulatory deterioration in GH, EPE and LPE. These associations have important clinical implications in terms of screening, diagnosis, prevention and management of gestational hypertensive diseases. They invite for further hypothesis-driven research on the role of retrograde venous congestion in the etiology of preeclampsia-related organ dysfunctions and their absence in GH, and also challenge the generally accepted view of abnormal placentation as the primary cause of preeclampsia. The striking similarity between abnormal maternal venous Doppler flow patterns and those observed at the ductus venosus and other abdominal veins of the intra-uterine growth restricted fetus, also invites to explore the role of venous congestion in the intra-uterine programming of some adult diseases. [ABSTRACT FROM AUTHOR]