The transitional phase of ductus venosus reversed flow in severely premature IUGR fetuses

The guiding hypothesis for this work is that in severe intrauterine growth-restricted (IUGR) fetuses, the time from ductus venosus (DV) reversed flow (RF) appearance to intrauterine fetal demise (IUFD) or nonreassuring fetal testing is variable. As such, there must be a transitional phase between the presence of end-diastolic forward flow (FF) and absent or reversed end-diastolic flow (A/REDF). Ductus venosus Doppler was serially studied in 19 IUGR fetuses (estimated fetal weight < 10th percentile and umbilical artery pulsatility index > 95th percentile) from diagnosis until demise or delivery occurring for nonreassuring fetal testing. Ductus venosus waveforms were assessed qualitatively: forward flow versus absent or reversed flow in diastole. Two sets of at least 30 consecutive ductus venosus waveforms were obtained at each examination. If the waveforms differed between the two sets, they were defined as alternating. Cord arterial pH and base excess (BE) were obtained at birth. In 14 cases, DVRF occurred intermittently between periods of FF during the same clinical visit. Intermittent DVRF was present from 2 to 57 days (median, 13 days) and became continuous from 1 to 23 days (median, 7 days) before the occurrence of delivery for nonreassuring fetal testing or fetal demise. One fetus had an abnormal arterial pH (< 7.0) and one had an abnormal BE (< -12). These data show that (1) there is a transitional phase in which DV alternates FF and A/RF before RF becomes persistent; (2) the time from the appearance of DVRF to delivery or IUFD is variable, and (3) not all very preterm IUGR fetuses with continuous DVRF are acidemic. Because of these findings, the decision of delivery regarding early severe IUGR fetuses should be individualized, and the DVRF Doppler information has to be integrated with other antenatal fetal parameters.