Presentation
Past history of pre-eclampsia.
Patient Data
Severe IUGR with an estimated fetal weight barely reaching 239g at 21WG (usually approx 500g is expected at this term). All biometric parameters < 3rd percentile.
Pathological umbilical Doppler with reversed diastolic flow.
Middle cerebral artery Doppler remained normal, indicating a relative vasodilation to preserve brain from damage: vascular redistribution, with a cerebro-placental ratio < 1, RI MCA / RI umbilical <1.
Ductus venosus Doppler: A wave is flat, which reflects increased filling pressure in the right atrium.
Bilateral uterine Dopplers showed protodiastolic notch (not shown), which is a non-relevant finding at this stage with obvious abnormal umbilical Doppler.
Placenta had a round shape with poor basal surface area and echoic aspect.
Case Discussion
Typical findings of a vascular IUGR occurring in early pregnancy, with already severe findings. In theory, US anomalies occur in the following order: Uterine notches -> asymmetrical IUGR -> umbilical Doppler with high RI -> fetal redistribution to preserve brain -> brain growth not preserved: symmetrical IUGR -> reverse diastolic flow in umbilical cord -> tricuspid insufficiency then elevated right atrium pressure: flat A wave on ductus -> cardiac failure -> intrauterine death.
Identification of such situations is critical to monitor properly:
maternal consequences on blood pressure and related CNS, kidney and liver disorders
fetal demise with intrauterine fetal death