Duration of persistent abnormal ductus venosus flow and its impact on perinatal outcome in fetal growth restriction

Objective To study if the duration of individual Doppler abnormalities is an independent predictor of adverse outcome in fetal growth restriction (FGR) caused by placental dysfunction. Methods This was a secondary analysis of patients with FGR (abdominal circumference < 5(th) percentile and umbilical artery (UA) pulsatility index (PI) elevation) who had at least three examinations before delivery. Days of duration of absent/reversed UA end-diastolic velocity (UA-AREDV), low middle cerebral artery PI (brain sparing), ductus venosus (DV) and umbilical vein Doppler abnormalities were related to stillbirth, major neonatal morbidity and intact survival. Results One hundred and seventy-seven study participants underwent a total of 1069 examinations. The duration of an absent/reversed a-wave in the DV (DV-RAV) was significantly higher in stillbirths (median, 6 days) compared with intact survivors and those with major morbidity (median, 0 days for both; P = 0.006 and P = 0.001, respectively). Duration of brain sparing was also longer in stillbirth cases compared with intact survivors (median, 19 days vs. 9 days, P = 0.02). Stepwise multinomial logistic regression showed that gestational age at delivery was a significant codeterminant of outcome for all arterial Doppler abnormalities when the DV a-wave was antegrade. However, when present, the duration of DV-RAV was the only contributor to stillbirth (probability of stillbirth = 1/(1 + exp - (interval to delivery x 1.03 - 2.28)), r(2) = 0.73). Receiver-operating characteristics curve statistics showed that a DV-RAV for >7 days predicted stillbirth (100% sensitivity, 80% specificity, likelihood ratio = 5.0, P < 0.0001). In contrast, neither neonatal death nor neonatal morbidity was predicted by the days of persistent DV-RAV. Conclusions The duration of absent or reversed flow during atrial systole in the DV is a strong predictor of stillbirth that is independent of gestational age. While prematurity remains the strongest predictor of neonatal risks it is unlikely that pregnancy can be prolonged by more than 1 week in this setting. Copyright. (C) 2011 ISUOG. Published by John Wiley & Sons, Ltd.