01 PHYSIOLOGY

39. Fetal circulation

The simplest way to tackle this subject is to draw this schematic diagram and use it in your subsequent discussion.
This diagram looks busy at first, but don’t be put off, it’s very simple to draw after a few goes.

Inferior 40% of
Umbilical Vein Vena Cava Total blood flow
Right
pO2 4.7
Atrium

60% of Total blood flow

Sats 80 – 90% Sats 20 – 40%
Foramen Ovale

Left Right
Atrium Ventricle

Pulmonary
Left
Lungs Artery
To Placenta Body Ventricle
Mother
10%RVEF
Sats 65%

Umbilical Artery Aorta

pO2 2.7 Ductus arteriosus
90% RVEF
RVEF = right ventricular ejection fraction

Fig. 39.1  Schematic of fetal circulation

Can you describe the fetal Talking it through, start at the placenta.
circulation? • Gas and waste exchange occurs at the placental bed. Oxygenated blood
then flows from the placenta towards the fetus, via the umbilical vein.
• It enters the fetus and flows up the inferior vena cava to the right atrium.
• From here, ~60% of the blood flows through the foramen ovale, from
right to left atrium. This blood travels from the left atrium to the left
ventricle and from here is pumped out into the aorta to circulate to the
brain, heart and body.
• The other 40% passes from the right atrium to the right ventricle. This
ventricle contracts ejecting blood into the pulmonary artery. However,
because of the high resistance afforded by the lungs, only 10% of this
blood flows through the pulmonary bed; the other 90% follows the
path of least resistance and flows through the ductus arteriosus to the
descending aorta. Here, it joins the blood that originally flowed through
the foramen ovale to left side of the heart.
• The blood continues its journey to and through the body, ultimately
leaving the fetus to return to the placental bed, via the umbilical arteries,
which arise from the common iliac arteries. (N.B. There are two umbilical
arteries and one vein.)

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 FETAL CIRCULATION

How is preferential oxygenation to • The pO2 in the umbilical vein is only ~4.7 kPa, representing saturations of
the major organs achieved? 80–90%, and so the fetus is hypoxaemic when compared to the mother.
• Blood arriving in the right atrium from the inferior vena cava has
saturations of ~60%, as it is composed of blood from the umbilical vein,
mixed with deoxygenated blood returning from the body.
• The blood returning to the RA from the superior vena cava is even
more deoxygenated, with sats of ~25%, because of the relatively high
oxygen extraction of the brain. Clearly, it is sensible for this blood to be
returned to the placental bed for re-oxygenation via as direct a route as
possible, and certainly not to be re-introduced to the cerebral circulation.
This is achieved by a structure called the Eustachian valve, a tissue flap
found at the junction of the inferior vena cava and right atrium. It causes
preferential ‘streaming’ of the more highly oxygenated inferior vena cava
blood straight across the foramen ovale, to the left atrium to be expelled
in to the aorta and therefore supply the brain. The less oxygenated blood
of the superior vena cava ‘falls’ into the right ventricle to be distributed to
the lungs and through the ductus arteriosus. This blood rejoins the aorta
at a point distal to the origin of the carotids, therefore ensuring that the
brain and heart are supplied with the most oxygen-rich blood.
Can you describe the changes that Several things happen here, we think it’s best to break it down in to stages
take place in the fetal circulation when trying to explain it:
at birth?
The gasp
As the baby is born it takes its first breath, often called a gasp. The
generation of negative intrathoracic pressure alters Starling’s forces across
the pulmonary vessels and helps to reduce the amount of interstitial fluid in
the lungs. A dramatic drop in pulmonary vascular resistance follows, allowing
an increase in blood flow through the lungs. As a result, more blood returns
to the left atrium from the lungs. This increases left-sided pressures in the
heart, causing mechanical closure of the foramen ovale. So, yet more blood
flows though the pulmonary bed as it now has no other path to go by, and
this maintains the foramen ovale’s closure.
Clamping the cord
As the cord is clamped, the ultra low-pressure placental circulation is
removed from the baby. This causes a rise in systemic vascular resistance,
and the removal of the blood from the placental circulation causes a
reduction in venous return to the heart. This decreases right atrial filling
pressures, therefore increasing further the pressure gradient between the left
and right atria, helping further to keep the foramen ovale closed.
The ductus arteriosus
There is a net reduction in the amount of blood being shunted across the
ductus arteriosus, as the pulmonary circulation is no longer a high-pressure
system. The gradient between pulmonary vessels and the aorta is reversed,
making the path through the lungs the one of least resistance.
In addition to this, the baby’s blood now has a higher pO2 than it did as
a fetus. The movement of this more highly oxygenated blood across the
ductus arteriosus stimulates its closure. The ductus arteriosus is closed
physiologically at around 15 hours after birth, and anatomically by 15 days.
Oxygen, bradykinins and prostaglandin antagonists (e.g. indomethacin)
accelerate ductus arteriosus closure, while PGE1 (e.g. alprostdil) and
conditions causing a raised pulmonary vascular resistance such as cold
and acidosis help to keep it open. It is important therefore to keep neonates
warm, oxygenated and hydrated (warm, wet and pink) to prevent their
reverting to a fetal circulation, which can be disastrous as they obviously no
longer have the ability to oxygenate themselves via a placenta.

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