Valvuloplasty in 103 fetuses with critical aortic stenosis: outcome and new predictors for postnatal circulation.

OBJECTIVES: To review our experience with fetal aortic valvuloplasty (FAV) in fetuses with critical aortic stenosis (CAS) and evolving hypoplastic left heart syndrome (eHLHS), including short- and medium-term postnatal outcome, and to refine selection criteria for FAV by identifying preprocedural predictors of biventricular (BV) outcome. METHODS: This was a retrospective review of all fetuses with CAS and eHLHS undergoing FAV at our center between December 2001 and September 2020. Echocardiograms and patient charts were analyzed for pre-FAV ventricular and valvular dimensions and hemodynamics and for postnatal procedures and outcomes. The primary endpoints were type of circulation 28 days after birth and at 1 year of age. Classification and regression-tree analysis was performed to investigate the predictive capacity of pre-FAV parameters for BV circulation at 1 year of age. RESULTS: During the study period, 103 fetuses underwent 125 FAVs at our center, of which 87.4% had a technically successful procedure. Technical success per fetus was higher in the more recent period (from 2014) than in the earlier period (96.2% (51/53) vs 78.0% (39/50); P = 0.0068). Eighty fetuses were liveborn after successful intervention and received further treatment. BV outcome at 1 year of age was achieved in 55% of liveborn patients in our cohort after successful FAV, which is significantly higher than the BV-outcome rate (23.7%) in a previously published natural history cohort fulfilling the same criteria for eHLHS (P = 0.0015). Decision-tree analysis based on the ratio of right to left ventricular (RV/LV) length combined with LV pressure (mitral valve regurgitation maximum velocity (MR-Vmax)) had a sensitivity of 96.97% and a specificity of 94.44% for predicting BV outcome without signs of pulmonary arterial hypertension at 1 year of age. The highest probability for a BV outcome was reached for fetuses with a pre-FAV RV/LV length ratio of < 1.094 (96.4%) and for those fetuses with a RV/LV length ratio ≥ 1.094 to < 1.135 combined with a MR-Vmax of ≥ 3.14 m/s (100%). CONCLUSIONS: FAV could be performed with high success rates and an acceptable risk with improving results after a learning curve. Pre-FAV RV/LV length ratio combined with LV pressure estimates were able to predict a successful BV outcome at 1 year of age with high sensitivity and specificity. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Fetal aortic valvuloplasty may rescue fetuses with critical aortic stenosis and hydrops.

OBJECTIVE: Critical aortic stenosis (CAS) with a restrictive interatrial septum may lead to fetal congestive heart failure and hydrops, usually culminating in fetal demise if left untreated. The aim of this study was to assess the effects of fetal aortic valvuloplasty (FAV) on hemodynamics and outcome in these patients. METHODS: This was a retrospective review of fetuses with CAS and signs of hydrops that underwent FAV in our center between 2000 and 2020. Echocardiograms and patients' charts were analyzed for ventricular and valvular dimensions and for outcome. RESULTS: Hydrops was present at the time of intervention in 15 fetuses with CAS that underwent FAV at our center during the study period. All but one patient had at least one technically successful procedure. There were no procedure-related deaths, but three intrauterine deaths occurred. Twelve subjects were liveborn, of whom two died within 24 h after birth owing to persistent hydrops. Ventricular function improved and hydrops resolved within 3-4 weeks after FAV in 71.4% (10/14) of fetuses with a technically successful intervention. A biventricular outcome was achieved in 50% of the successfully treated patients. CONCLUSIONS: Fetuses with CAS and hydrops can be successfully treated with FAV. The procedure has the potential to restore sufficient fetal cardiac output, which may lead to resolution of hydrops. Surviving patients seem to be good candidates for a biventricular outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Immediate effects and outcome of in-utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis.

OBJECTIVE: To assess the immediate effects of fetal pulmonary valvuloplasty on right ventricular (RV) size and function as well as in-utero RV growth and postnatal outcome. METHODS: Patients with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS) who underwent fetal pulmonary valvuloplasty at our center between October 2000 and July 2017 were included. Echocardiographic data obtained before and after the procedure were analyzed retrospectively (median interval after intervention, 1 (range, 1-3) days) for ventricular and valvular dimensions and ratios, RV filling time (duration of tricuspid valve (TV) inflow/cardiac cycle length), TV velocity time integral (TV-VTI) × heart rate (HR) and tricuspid regurgitation (TR) velocity. Longitudinal data were collected from only those fetuses followed up in our center. Outcome was assessed using the scoring system as described by Roman et al. for non-biventricular outcome. RESULTS: Thirty-five pulmonary valvuloplasties were performed in our institution on 23 fetuses with PAIVS (n = 15) or CPS (n = 8). Median gestational age at intervention was 28 + 4 (range, 23 + 6 to 32 + 1) weeks. No fetal death occurred. Immediately after successful intervention, RV/left ventricular length (RV/LV) ratio (P ≤ 0.0001), TV/mitral valve annular diameter (TV/MV) ratio (P ≤ 0.001), RV filling time (P ≤ 0.00001) and TV-VTI × HR (P ≤ 0.001) increased significantly and TR velocity (P ≤ 0.001) decreased significantly. In fetuses followed longitudinally to delivery (n = 5), RV/LV and TV/MV ratios improved further or remained constant until birth. Fetuses with unsuccessful intervention (n = 2) became univentricular, all others had either a biventricular (n = 15), one-and-a-half ventricular (n = 3) or still undetermined (n = 3) outcome. Five of nine fetuses with a predicted non-biventricular outcome, in which the procedure was successful, became biventricular, while two of nine had an undetermined circulation. CONCLUSION: In selected fetuses with PAIVS or CPS, in-utero pulmonary valvuloplasty led immediately to larger RV caused by reduced afterload and increased filling, thus improving the likelihood of biventricular outcome even in fetuses with a predicted non-biventricular circulation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Tissue Doppler imaging in fetuses with aortic stenosis and evolving hypoplastic left heart syndrome before and after fetal aortic valvuloplasty.

OBJECTIVES: Fetal aortic valvuloplasty can improve filling and reduce afterload of the left ventricle in critical aortic stenosis. Success of an intrauterine intervention is currently measured by technical success, clinical survival and eventual postnatal biventricular physiology. In the present study we investigated the use of tissue Doppler imaging (TDI) to evaluate changes in ventricular function assessed before and after prenatal aortic valvuloplasty. METHODS: Between October 2008 and December 2012, cardiac function was assessed by TDI before and after intervention in 23 fetuses that underwent technically successful valvuloplasty for critical aortic stenosis and in which postnatal outcome was known. The measurements were transformed into gestational age-independent Z-scores where appropriate. RESULTS: Mean ± SD gestational age at intervention was 27.5 ± 3.1 weeks. Of the 23 fetuses, 14 had biventricular outcome. Before intervention all left ventricular (LV) TDI-derived parameters and mitral annular plane systolic excursion (MAPSE) were severely abnormal. It was possible to demonstrate considerably improved cardiac function after technically successful valvuloplasty. Among fetuses with postnatal biventricular outcome, TDI-derived LV myocardial peak velocity during early diastole (E') and myocardial peak velocity during systole in the ejection phase (S') significantly increased, E'/myocardial peak velocity during late diastole with atrial contraction (A') increased towards normal values, and LV transmitral-to-mitral-annular diastolic velocity ratio (E/E') and myocardial performance index (MPI') decreased but remained abnormally elevated. In addition, right ventricular A', S' and MPI' significantly improved after intervention. CONCLUSION: Technically successful fetal aortic valvuloplasty led to significantly improved myocardial performance. It was possible to use TDI to detect distinct changes in ventricular function and TDI-derived parameters correlated with a biventricular outcome after birth. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Maternal aspects of fetal cardiac intervention.

OBJECTIVES: Fetal cardiac interventions have the potential to alter natural disease progression and reduce morbidity and mortality in children. Although there are already encouraging data on fetal outcome, information on maternal morbidity and mortality after intervention is scarce. The aim of the present study was to assess maternal aspects, pregnancy-associated risks and adverse events in 53 intrauterine cardiac interventions. METHODS: Between October 2000 and December 2012, 53 fetal cardiac interventions were performed in 47 patients (43 aortic valve dilations in 39 patients, seven pulmonary valve dilations in six patients and three balloon atrioseptostomies in two patients). Median gestational age was 26 + 4 (range, 20 + 3 to 33 + 1) weeks. Interventions were performed by an ultrasound-guided percutaneous approach under general anesthesia. All medical records and patient charts were analyzed retrospectively. RESULTS: All women were considered to be healthy in the preoperative assessment; 39 (83%) patients continued pregnancy until term and eight of 47 patients had an intrauterine fetal death (IUFD) and were induced. Postoperative nausea was reported in 29.8% of patients and abdominal pain in 36.2% of patients on the day of surgery. Preterm contractions were observed in two patients; no preterm prelabor rupture of membranes occurred. One severe postpartum hemorrhage was observed in a patient with IUFD and subsequent induction; however, this was unrelated to the balloon valvuloplasty. No intensive care unit admission and no major anesthesia-associated complications (aspiration, anaphylactic reaction, cardiovascular collapse, damage to teeth, laryngeal damage, awareness or hypoxic brain damage) were observed. Maternal mortality was zero. A significant learning curve was observed in terms of duration of intervention. CONCLUSION: In our experience, percutaneous needle-guided fetal cardiac intervention seems to be a safe procedure for the mother. In 53 procedures no major maternal complication directly related to the intervention was observed.

[Management of postpartum hemorrhage (PPH): algorithm of the interdisciplinary D-A-CH consensus group PPH (Germany - Austria - Switzerland)]. / Management der postpartalen Blutung (PPH): Algorithmus der Interdisziplinären D-A-CH-Konsensusgruppe PPH (Deutschland - Österreich - Schweiz).

Postpartum hemorrhage (PPH) is one of the main causes of maternal deaths even in industrialized countries. It represents an emergency situation which necessitates a rapid decision and in particular an exact diagnosis and root cause analysis in order to initiate the correct therapeutic measures in an interdisciplinary cooperation. In addition to established guidelines, the benefits of standardized therapy algorithms have been demonstrated. A therapy algorithm for the obstetric emergency of postpartum hemorrhage in the German language is not yet available. The establishment of an international (Germany, Austria and Switzerland D-A-CH) "treatment algorithm for postpartum hemorrhage" was an interdisciplinary project based on the guidelines of the corresponding specialist societies (anesthesia and intensive care medicine and obstetrics) in the three countries as well as comparable international algorithms for therapy of PPH.The obstetrics and anesthesiology personnel must possess sufficient expertise for emergency situations despite lower case numbers. The rarity of occurrence for individual patients and the life-threatening situation necessitate a structured approach according to predetermined treatment algorithms. This can then be carried out according to the established algorithm. Furthermore, this algorithm presents the opportunity to train for emergency situations in an interdisciplinary team.

[Closing gastroschisis: a distinct entity with high morbidity and mortality]. / Closing Gastroschisis: eine Sonderform der Gastroschisis mit hoher Morbidität und Mortalität.

PURPOSE: We correlate severe bowel damage in gastroschisis to the rare intrauterine event of narrowing of the abdominal wall around the protruding intestines. We describe this "closing gastroschisis" as a distinct entity. Prenatal ultrasound findings as gastric or bowel dilation were compared to the postnatal findings in order to find markers for an early in utero diagnosis of closing gastroschisis. Early diagnosis could prompt timely delivery to save the compromised bowel and avoid short gut syndrome. MATERIALS AND METHODS: We documented the pre- and postnatal course of our patients with gastroschisis from 2007 to 2009.  Closing gastroschisis was suspected antenatally and confirmed postnatally. We identified 5 out of 18 patients showing closure of the abdominal wall with varying degrees of bowel damage. Prenatal ultrasound findings were correlated to the postnatally confirmed extent of intestinal damage. RESULTS: We could not find consistent ultrasound markers for prenatal diagnosis of closing gastroschisis. In prenatal ultrasound three patients presented significant gastric dilation and then experienced severe courses postnatally due to segmental gut necrosis. One of these three died and the other two developed short gut syndrome. In one case progressive intraabdominal loop dilation with simultaneous shrinking of the extraabdominal loops occurred corresponding to closing gastroschisis with segmental midgut necrosis. CONCLUSION: Closing gastroschisis must be seen as a special form of gastroschisis. Extended intestinal damage is often life-threatening. In longitudinal observation dynamics of fetal ultrasound findings can lead to the diagnosis of closing gastroschisis. Progressive intraabdominal loop dilation is always highly suspicious and must lead to close follow-up and timely delivery.

[Effect of noninvasive first trimester diagnosis on indications and results of chorion villi sampling]. / Einfluss der nicht invasiven Ersttrimester-Diagnostik auf Indikationen und Ergebnisse der Chorionzottenbiopsien.

AIM: In this explorative study it should be evaluated how the introduction of non invasive first trimester diagnosis (nuchal translucency measurement, Combined Test, first trimester ultrasound screening) has influenced the indications and cytogenetic results of chorion villi samplings. MATERIALS AND METHODS: Between 1989 and 2008 3337 pregnancies with CVS between 11 and 14 weeks of gestation were examined retrospectively. They were divided in two groups: CVS 1989 - 2001 before introduction of non invasive first trimester diagnosis (n = 1698) and CVS 2002 - 2008 after introducing non invasive testing at the end of 2001 (n = 1639). In both groups the indications for CVS (maternal age, sonographic findings, past history, maternal anxiety, and abnormal results of the Combined Test only in the second group) and the cytogenetic results were evaluated. RESULTS: In the first group (1989 - 2001, n = 1698) 85,6% (n = 1454) of all CVS were performed because of maternal age and only 3% (n = 51) due to sonographic findings. In the second group (2002 - 2008, n = 1639) there was a distinct increase of sonographic findings leading to CVS (33,9%, n = 555) with a clear decrease of maternal age to 37,9% (n = 621). Abnormal cytogenetic results were found in 10,5% (n = 172) in the second group, in the first group only in 4,5% (n = 76), respectively. The parameter with the highest rate of chromosomal disorders was fetal hydrops (66,1%), follwed by hygroma colli (48,2%), malformations (12,9%) and increased nuchal translucency (11,2%). Regarding maternal age alone the rate of abnormal chromosomes was 3,1%. CONCLUSIONS: It could be shown that non invasive first trimester diagnosis has lead to a more specific indication for invasive fetal testing (sonographic findings 33,9 vs. 3%, maternal age 37,9 vs. 85,6%) with a higher rate of chromosomal disorder in this group (10,5 vs. 4,5%).

Intrauterine aortic valvuloplasty in fetuses with critical aortic stenosis: experience and results of 24 procedures.

OBJECTIVE: Valvuloplasty of the fetal aortic valve has the potential to prevent progression of critical aortic stenosis (AS) to hypoplastic left heart syndrome (HLHS). The aim of the study was to assess 24 aortic valvuloplasties regarding indications, success rate, procedure-related risks and outcome. METHODS: Between January 2001 and December 2009 we performed 24 aortic valvuloplasties in 23 fetuses with critical AS at a median gestational age of 26 + 4 (range, 21 + 3 to 32 + 5) weeks by a transabdominal ultrasound-guided approach. Four fetuses had hydrops as a late sign of heart failure. RESULTS: In 16/24 procedures (66.7%) corresponding to 16/23 fetuses (69.6%) the procedures were technically successful, with one intrauterine death in this group. After an initial learning curve, success rate improved to 78.6% (11 of the last 14 interventions were successful). In 10 out of the 15 (66.7%) successfully-treated and liveborn fetuses a biventricular circulation could be achieved postnatally. All four fetuses with hydrops had successful interventions, hydrops disappearing within 5 weeks. In 8/24 interventions (33.3%) the aortic valve could not be treated successfully, with intrauterine fetal death in two of these cases. In one fetus a repeat procedure was successful. All surviving fetuses with unsuccessful (n = 5) or no (n = 5) procedure performed developed HLHS until delivery. CONCLUSIONS: Fetal aortic valvuloplasty could be performed successfully in selected fetuses with critical AS and evolving HLHS, with a biventricular outcome in two thirds of the patients. Safety and success rate were dependent on patient selection and the level of experience of the whole interventional team. In fetuses with AS and hydrops, aortic valvuloplasty could reverse end-stage heart failure and hydrops and ensure fetal survival.

Easy sperm processing technique allowing exclusive accumulation and later usage of DNA-strandbreak-free spermatozoa.

Sperm DNA fragmentation is increased in poor-quality semen samples and correlates with failed fertilization, impaired preimplantation development and reduced pregnancy outcome. Common sperm preparation techniques may reduce the percentage of strandbreak-positive spermatozoa, but, to date, there is no reliable approach to exclusively accumulate strandbreak-free spermatozoa. To analyse the efficiency of special sperm selection chambers (Zech-selectors made of glass or polyethylene) in terms of strandbreak reduction, 39 subfertile men were recruited and three probes (native, density gradient and Zech-selector) were used to check for strand breaks using the sperm chromatin dispersion test. The mean percentage of affected spermatozoa in the ejaculate was 15.8 ± 7.8% (range 5.0­42.1%). Density gradient did not significantly improve the quality of spermatozoa selected(14.2 ± 7.0%). However, glass chambers completely removed 90% spermatozoa showing strand breaks and polyethylene chambers removed 76%. Both types of Zech-selectors were equivalent in their efficiency, significantly reduced DNA damage (P < 0.001) and,with respect to this, performed better than density gradient centrifugation (P < 0.001). As far as is known, this is the first report ona sperm preparation technique concentrating spermatozoa unaffected in terms of DNA damage. The special chambers most probably select for sperm motility and/or maturity.

Group culture of human zygotes is superior to individual culture in terms of blastulation, implantation and life birth.

This prospective study tested a new type of culture dish for the effects of individual culture and autotrophic factors. Within a 6-month period, 72 patients with nine or more fertilized eggs were enrolled in this prospective evaluation. Their 936 zygotes were split into three subgroups (individual culture, individual culture with contact to neighbours, group culture). All concepti were cultured in 30 µl drops (medium change on day 3) until blastocyst stage. On day 5, a single-blastocyst transfer was performed and the remaining blastocysts of good quality were vitrified. Fertilization rates were 69% for IVF and 81% for intracytoplasmic sperm injection. Blastulation was 48%. Single-blastocyst transfer resulted in a clinical pregnancy rate of 54%. Group culture was superior in terms of compaction (P<0.01) and blastulation (P<0.001) as compared with individual culture. A better blastocyst quality was observed in group culture (P<0.05). As a trend, more life births were achieved with blastocysts derived from group culture. As far as is known, this is the first evidence that grouping embryos improves preimplantation development in human and it is recommended that culture volume should be reduced or embryo density increased.

Invasive intrauterine treatment of pulmonary atresia/intact ventricular septum with heart failure.

The mortality and morbidity of children with pulmonary atresia/intact ventricular septum (PA/IVS) are linked to the degree of right ventricular (RV) hypoplasia. Opening up the pulmonary valve (PV) in fetal life could result in improved growth of the RV making it amenable to biventricular repair postnatally. Successful valvulotomy of the PV was performed in a fetus with heart failure at 28 weeks. Following the procedure there was significant growth of the tricuspid valve and RV. The neonate was delivered at 38 weeks with a RV suitable for biventricular repair. In utero pulmonary valvulotomy is feasible and may change the natural history of the condition in affected fetuses with PA/IVS.

[Real time 3D sonography of the normal fetal heart--clinical evaluation]. / Klinische Evaluierung der Realtime-3D-Sonographie beim normalen fetalen Herzen.

AIM: Aim of the study was to determine the clinical feasibility of real time 3D ultrasound in the examination of the normal fetal heart compared to conventional 2D fetal echocardiography. METHOD: Twenty fetuses with normal hearts at 20 to 38 weeks of gestation underwent real time 3D ultrasound. Examination data were stored on an external notebook. Later analysis and interpretation was done by a different sonographer using a special software. RESULTS: In the assessment of the four chamber view and the out flow tracts real time 3D ultrasound was equivalent to conventional ultrasound. Advantages of realtime 3D ultrasound were the possibility of later time-independent off-line analysis and post-processing of volume data and generation of new views not available in 2D imaging. Disadvantages included low frame rate (16 frames/s), low lateral resolution and the lack of Doppler and colour information. CONCLUSION: Simultaneous display of 3 different views of the fetal heart as well as the construction of spatial perspectives ("new views") provide additional useful information to conventional fetal echocardiography. Later off-line analysis of 3D volume data can be used for sequential analysis of the normal fetal heart with good diagnostic results. Currently it remains unclear whether this new method may provide additional important information in the assessment of fetal congenital heart defects.

[Spontaneous constriction of the fetal ductus arteriosus]. / Spontane Konstriktion des fetalen Ductus arteriosus.

The case report describes the pre- and postnatal clinical and sonographic findings of a fetus with spontaneous constriction of Ductus arteriosus at 39 weeks gestation. An abnormal four-chamber view due to a hypertrophied and enlarged right ventricle, increased peak systolic (2.39 m/sec), increased peak diastolic (0.88 m/sec) velocities and the decreased pulsatility index of 0.92 were the diagnostic criteria. The flow of the right pulmonary artery was retrograde. After birth estimated pulmonary pressure was 50 mmHg. It is concluded that constriction of the fetal ductus arteriosus may also occur spontaneously in the absence of maternal drugs.

[Doppler ultrasound of the umbilical vein in fetal 3rd degree atrioventricular block]. / Doppler der Nabelvene beim fetalen AV-Block 3. Grades.

A 21 week fetus was diagnosed with complete heart block. From the first diagnosis until 38 weeks gestation, umbilical venous pulsations occurred during ventricular systole. The ventricular frequency was 49 bpm. The venous pulsations corresponded with the ventricular frequency. At 38 weeks venous pulsations also occurred during ventricular diastole. Umbilical pulsations during diastole were associated with a decrease of ventricular frequency to 28 bpm and fetal hydrops. The venous pulsations during ventricular systole seem to be characteristic of complete heart block. The pulsations during ventricular diastole reflect the fetal heart failure. Doppler ultrasound aids in the diagnosis and surveillance of the fetus with complete heart block.

[Pulsations of the umbilical vein: pathophysiologic aspects and fetal outcome]. / Pulsationen der Nabelvene: pathophysiologische Aspekte und fetal outcome.

Continuous forward flow to the fetal heart in the umbilical vein is a normal Doppler finding. Altered fetal hemodynamics can cause a pulsatile flow pattern in the umbilical vein. Pulsations in the umbilical vein were diagnosed in 14 pregnancies complicated by fetal hydrops, cardiac malformations, arrhythmia or severe intrauterine growth retardation. To document the fetal outcome, the results were analysed retrospectively. Compared with a normal Doppler group (N = 56), a significantly higher rate of perinatal death (Alpha < 1%), (64% vs 1.75%) was diagnosed, when pulsations in the umbilical vein were present. The Apgar-score was significantly lower (4.5 vs 8.4) (p < 0.0002) in the group with pulsations in the umbilical vein. There was no significant difference of pH between the newborns of the two groups. Eight fetuses developed hydrops. Thirteen fetuses had increased reverse flow in the inferior vena cava. The vena cava of the acardiac fetus could not be identified. The knowledge of the poor outcome and the pathophysiologic relationships of fetal hemodynamics may be useful in clinical management. Therefore Doppler examination of the umbilical vein should be performed in high-risk pregnancies.

[Fetal outcome in reduced flow in the ductus venosus during atrial contraction]. / Das Schicksal des Feten mit reduziertem Fluss des Ductus venosus während der Vorhofkontraktion.

OBJECTIVE: To document the fetal outcome in cases with pathologic Doppler findings in the fetal ductus venosus. METHODS: The outcome of 12 fetuses with reduced velocities in the ductus venosus during atrial contraction was analyzed retrospectively and compared with that of a group of 57 fetuses with normal flow velocities in the umbilical artery and in the fetal ductus venosus. RESULTS: The perinatal mortality was higher in the group with pathologic Doppler findings. There was no significant difference of pH (7.20 vs. 7.24) and Apgar scores (7.57 vs. 8.36) of survivors between the two groups. All 12 fetuses showed increased retrograde velocities in the inferior vena cava. Seven fetuses showed umbilical vein pulsations. CONCLUSIONS: The diagnosis of altered velocities in the ductus venosus may influence prenatal decisions. Therefore Doppler examinations of the fetal ductus venosus should be performed in high-risk pregnancies.

[Tetralogy of Fallot with absent pulmonary valve--prenatal diagnosis and management in the 2nd trimester]. / Fallotsche Tetralogie mit fehlender Pulmonalklappe--pränatale Diagnose und Management im II. Trimester.

Tetralogy of Fallot with absent pulmonary valve is a rare congenital cardiac malformation detected in 3% to 6% of tetralogy of Fallot patients. The prognosis depends on respiratory complications. In the present case the diagnosis was made at 18 week's gestation with two-dimensional and Doppler echocardiography. A ventricular septal defect and overriding aorta, absent valve echo, pulmonary regurgitation, and cystic pulsatile dilatation of the left pulmonary artery were the main diagnostic criteria. Severe respiratory complications were assumed in combination with a hyperechogenic left lung and termination of pregnancy was performed at 20 weeks' of gestation.