Blood flow redistribution in the fetal umbilical-portal venous system in pregnancy complicated by diabetes mellitus

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Abstract

BACKGROUND: The fetal liver plays a central role in energy metabolism and is supplied mainly by the vessels of the umbilical-portal venous system. Redistribution of blood flow in this system is a key adaptive response of the fetus to environmental change.

AIM: The aim of this study was to evaluate the hemodynamic redistribution in the fetal umbilical-portal venous system in pregnant women with pregestational diabetes mellitus, gestational diabetes mellitus and in healthy pregnant women.

MATERIALS AND METHODS: This prospective cohort single-center study was conducted at the Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott, Saint Petersburg between February 2022 and September 2023. The study included 188 patients who made up the following comparison groups: pregestational diabetes mellitus (n = 86), gestational diabetes mellitus (n = 44), and control (n = 58). Patients underwent ultrasound from 30+0 to 41+3 weeks with assessment of venous hemodynamics in the vessels of the umbilical-portal venous system such as the umbilical vein, left portal vein, right portal vein, main portal vein, and ductus venosus.

RESULTS: The umbilical vein volumetric blood flow in the I group exceeded that in the II group by 23.60 ml/min/kg and that in the control group by 30.35 ml/min/kg (p < 0.001). The total liver volumetric blood flow in patients with pregestational diabetes mellitus (106.85 ml/min/kg) also exceeded that in the gestational diabetes mellitus group by 28.04 ml/min/kg and that in the control group by 33.73 ml/min/kg (p < 0.001). The umbilical vein and total fetal liver blood flows increased to full-term pregnancy, but, when normalized by the estimated fetal weight, the both flows showed a downward trend at 37–41 weeks of gestation (p < 0.001). No significant differences were revealed in the ductus venosus volumetric blood flow in the study groups. However, there was a significant decrease in the ductus venosus shunt fraction in patients with pregestational diabetes mellitus (16.83 %) by −8.34 % compared to the control group (24.56 %) and by −5.65 % compared to the II group (22.89 %). The downward trend persisted throughout the third trimester of pregnancy and reached its maximum at full-term (p < 0.001).

CONCLUSIONS: With pregestational diabetes mellitus, there is a priority redistribution of highly oxygenated blood from the umbilical vein to the right lobe of the fetal liver, accompanied by a decrease in the ductus venosus shunt fraction. This may underlie the pathogenesis of such complications as fetal macrosomia and diabetic fetopathy.

About the authors

Ekaterina V. Kopteeva

The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott

Email: ekaterina_kopteeva@bk.ru
ORCID iD: 0000-0002-9328-8909
SPIN-code: 9421-6407

MD

Russian Federation, 3 Mendeleevskaya Line, Saint Petersburg, 199034

Elizaveta V. Shelaeva

The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott

Email: eshelaeva@yandex.ru
ORCID iD: 0000-0002-9608-467X
SPIN-code: 7440-0555

MD, Cand. Sci. (Med.)

Russian Federation, 3 Mendeleevskaya Line, Saint Petersburg, 199034

Elena N. Alekseenkova

The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott

Email: ealekseva@gmail.com
ORCID iD: 0000-0002-0642-7924
SPIN-code: 3976-2540

MD

Russian Federation, 3 Mendeleevskaya Line, Saint Petersburg, 199034

Roman V. Kapustin

The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott

Email: kapustin.roman@gmail.com
ORCID iD: 0000-0002-2783-3032
SPIN-code: 7300-6260

MD, Dr. Sci. (Med.)

Russian Federation, 3 Mendeleevskaya Line, Saint Petersburg, 199034

Igor Yu. Kogan

The Research Institute of Obstetrics, Gynecology and Reproductology named after D.O. Ott

Author for correspondence.
Email: ikogan@mail.ru
ORCID iD: 0000-0002-7351-6900
SPIN-code: 6572-6450

MD, Dr. Sci. (Med.), Professor, Corresponding Member of the Russian Academy of Sciences

Russian Federation, 3 Mendeleevskaya Line, Saint Petersburg, 199034

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2. Fig. 1. The schematic view of the fetal umbilical-portal venous system: a, cross section of the abdominal cavity of the fetus, arrows indicate physiological directions of blood flow in the fetal liver (adapted from [19]); b, visualization of the fetal umbilical-portal venous system in 3D HD-Flow mode. UV, umbilical vein; LPV, left portal vein; RPV, right portal vein; MPV, main portal vein; НПВ, inferior vena cava; DV, ductus venosus

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3. Fig. 2. The main sections for visualizing the vessels of the fetal umbilical-portal venous system. a, oblique transverse section of the fetal abdomen, in which the entry of the umbilical vein into the liver, the ductus venosus, which is characterized by turbulent staining of the blood flow, and the left portal vein, which is a direct continuation of the umbilical vein, are visualized; b, Oblique transverse section of the fetal abdomen to visualize the connection of the left portal vein and the main portal vein, which form the right portal vein. UV, umbilical vein; LPV, left portal vein; RPV, right portal vein; MPV, main portal vein; DV, ductus venosus

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4. Fig. 3. Volumetric blood flow (Q) of the vessels of the fetal umbilical-portal venous system in the study groups: a, in umbilical vein; b, Left portal vein; c, right portal vein. GDM, gestational diabetes mellitus; PGSD, pregestational diabetes mellitus. * Significance level р < 0.05

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5. Fig. 4. Volumetric blood flow (Q) of the fetal liver in the III trimester of pregnancy in the study groups: a, in left lobe of the liver; b, in right lobe of the liver; c, total liver blood flow. GDM, gestational diabetes mellitus; PGSD, pregestational diabetes mellitus. * Significance level р < 0.05

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6. Рис. 5. Фракции шунтирования в исследуемых группах: а — в венозном протоке; b — в главной портальной вене. ГСД — гестационный сахарный диабет; ПГСД — прегестационный сахарный диабет. * Уровень значимости р < 0,05

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7. Fig. 6. Linear mixed models. Changes depending on the gestational age in the study groups: a, umbilical vein volumetric blood flow; b, normalized umbilical vein volumetric blood flow; c, total liver volumetric blood flow; d, normalized total volumetric liver volumetric blood flow. Data are presented as means with 95 % confidence intervals. No overlap of the 95 % confidence interval indicates significant differences between the groups. Q, volumetric blood flow; GDM, gestational diabetes mellitus; PGSD, pregestational diabetes mellitus

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8. Fig. 7. Linear mixed models. Changes in the ductus venosus shunt fraction depending on the gestational age in the study groups. Data are presented as means with 95 % confidence intervals. No overlap of the 95 % confidence interval indicates significant differences between the groups. GDM, gestational diabetes mellitus; PGSD, pregestational diabetes mellitus

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