Foetal circulation

 Dr. A. HARICHARAN.
MD,DHA,
PGDCP ( Criminal Psychology ).
 Senior Resident
DEPT. of FORENSIC MEDICINE &
TOXICOLOGY
 definition

The foetal circulation is the circulatory

system of a human foetus, often encompassing
the entire foeto-placental circulation which
includes the umbilical cord and the blood
vessels within the placenta that carry foetal
blood.
The development of foetal circulatory system

 Heart begins to develop towards the

end of the 3rd week.
 It starts beating at the beginning
of the 4th week.
 The critical period of heart
development is between the 20th to
50th day after fertilization.
 Many critical events occur during
cardiac development, and any
deviation from this normal pattern
can cause congenital heart defects.
Why Foetal circulation?
 Foetal circulation differs from the adult
one predominantly due to the presence of 3
major vascular shunts:

 Ductus arteriosus: between the pulmonary

artery and descending aorta
 Foramen ovale: between the right and left
atrium
 Ductus venosus: between the umbilical vein
and IVC
 The foetal circulation works differently
from that of a born humans, mainly
because the lungs are not in use: the foetus
obtains oxygen and nutrients from the
mother’s placenta through the umbilical
cord.
Umbilical Cord

 2 umbilical arteries

 1 umbilical vein
Umbilical circulation

 Pair of umbilical
arteries carry
deoxygenated blood &
wastes to placenta.
 Umbilical vein carries
oxygenated blood and
nutrients from the
placenta.
PLACENTA
 Organ that connects the developing
foetus to the uterine wall to allow
nutrients uptake, waste elimination,
and gas exchange via the mother's
bloods
 two components: the foetal
placenta, or (Chorion frondosum),
which develops from the foetus; and
the maternal placenta, or (Decidua
basalis), which develops from the
maternal uterine tissue
 Facilitates gas and nutrients
exchange between maternal and
foetal blood.
PLACENTAL ROLE

 The core concept behind foetal circulation is that

foetal hemoglobin has a higher affinity for
oxygen than does adult hemoglobin, which allows a
diffusion of oxygen from the mother's circulatory
system to the foetus.

 The circulatory system of the mother is not directly

connected to that of the foetus, so the placenta
functions as the respiratory center for the foetus
as well as a site of filtration for plasma nutrients
and wastes.
 Water, glucose, amino acids, vitamins, and
inorganic salts freely diffuse across the placenta
along with oxygen.

 The umbilical arteries carry blood to the

placenta, and the blood permeates the sponge-like
material there. Oxygen then diffuses from the
placenta to the chorionic villus, an alveolus-like
structure, where it is then carried to the umbilical
vein.
 Section through the human placenta, showing the
way the fetal villi project into the maternal sinuses

 Maternal blood is delivered

to the intervillous space of
the chorionic plate,
 bathes the chorionic villi
that carry umbilical
capillary beds, allowing
foetal/maternal gas
exchange
 the deoxygenated blood
returns via open ended
venules
Course of fetal circulation

1.Placenta:
 Has the lowest
vascular
resistance in the
foetus.
 Receives the
largest amount
of combined (Rt
+ Lt)Ventricular Placenta
Output (55%)
Course of fetal circulation

2. Superior Vena Cava:

 Drains the upper

part of the
body,including the
brain (15% of
combined
ventricular output).
 Most of SVC blood
goes to the Right
Ventricle.
 Course of fetal circulation
3. Inferior Vena Cava:
 Drains lower part of body
and placenta (70% of
combined ventricular
output)
 Part of IVC blood with high
O2 goes into LA via
Foramen Ovale.
 Remaining IVC blood enter
RV and Pulmonary artery.
 Since blood is oxygenated
in the placenta, Oxygen
saturation in IVC (PO2 =
26-28%) is higher than
that in SVC (12-14%).
 #Course of fetal circulation
 Most of SVC blood (less
oxygenated blood) goes into RV.
 Most of IVC blood (high O2
concentration) is directed by the
Crista Dividens to the LA
through Foramen ovale.
 Rest of IVC blood enters RV &
pulmonary artery.
 Less oxygenated blood in
Pulmonary artery flows through
Ductus Arteriosus to
descending aorta and then to
placenta for oxygenation.
Foetal circulation pathway

Placenta

Oxygenated blood

Umbilical vein

Hepatic circulation Bypasses liver & joins IVC

via ductus venosus

Partially mixes with poorly oxygenated IVC blood derived from

lower part of fetal body
 Combined lower body blood with umbilical venous blood flow
(PO2 of ≈26–28 mm Hg) passes through IVC to the Right
atrium and is preferentially directed across the foramen
ovale to the left atrium.

The blood then flows into the left ventricle and is ejected into
the ascending aorta.

Foetal SVC blood, which is considerably less oxygenated (PO2 of

12–14 mm Hg), enters the Right atrium and preferentially
traverses the tricuspid valve, rather than the foramen ovale,
and flows primarily to the right ventricle.
 Pulmonary artery
(Because the pulmonary arterial circulation is
vasoconstricted, only about 10% of right ventricular
outflow enters the lungs)

The rest 90% blood (which has a PO2 of ≈18–22 mm Hg)

bypasses the lungs and flows through the Ductus Arteriosus
into the Descending Aorta to perfuse the lower part of the
foetal body.

Umbilical arteries.

Placenta
Foetal circulation pathway
 Thus, upper part of foetal body (including coronary & cerebral arteries
and those to upper extremities) is perfused exclusively from the Left
ventricle with blood that has a slightly higher PO2 , than the blood
perfusing the lower part of the foetal body, which is derived mostly
from the Right ventricle.

 The total foetal cardiac output—the combined output of both

the left and right ventricles—is ≈ 350 mL/kg/min.
 Descending aortic blood flow :
-65% returns to placenta;
-Remaining 35% perfuses the foetal organs & tissues.

 Right ventricular output is about 1.3 times the left ventricular

flow.
 Thus, during foetal life the right ventricle
-is pumping against systemic blood pressure
-is performing greater volume of work than LV.
 • During foetal life350ml per kg
per min
Cardiac
Output
• Following birth 500ml per min

Heart • 120-140per min

Rate
Blood pressure
 It is the foetal heart and not the mother's heart that builds
up the foetal blood pressure to drive its blood through the
foetal circulation.
 Intracardiac pressure remains identical between the right
and left ventricles of the human foetus.
 The blood pressure in the foetal aorta is approximately 30
mmHg at 20 weeks of gestation, and increases to ca 45
mmHg at 40 weeks of gestation. The foetal pulse pressure is
ca 20 mmHg at 20 weeks of gestation, increasing to ca 30
mmHg at 40 weeks of gestation.
 The blood pressure decreases when passing through the
placenta. In the arteria umbilicalis, it is ca 50 mmHg. It falls
to 30 mmHg in the capillaries in the villi. Subsequently, the
pressure is 20 mm Hg in the umbilical vein, returning to the
heart.
Circulatory changes at birth

 The change from foetal to postnatal

circulation
happens very quickly.

 Changes are initiated by baby’s first

breath.

 Changes in the vascular system are

caused by cessation of placental blood
flow and the beginning of respiration.
 At BIRTH

Mechanical expansion of lungs Increase in arterial PO2

Rapid DECREASE in pulmonary vascular resistance

Removal of the low-resistance placental circulation

INCREASE in systemic vascular resistance

 Right ventricle output now flows entirely into the
pulmonary circulation.

Pulmonary vascular resistance becomes lower than

systemic vascular resistance,

Shunt through Ductus Arteriosus reverses &

becomes left to right.
 High arterial PO2 (In several days)

Constriction of Ductus Arteriosus

It closes, becoming the Ligamentum

Arteriosum.
Increased volume of pulmonary blood flow returning to
left atrium

Increases left atrial volume and pressure

Closure of Foramen Ovale (functionally) (Although the

foramen may remain probe patent)

Becomes Fossa Ovalis

 Removal of the placenta from the circulation

Also results in closure of the Ductus Venosus

 The left ventricle is now coupled to the high-

resistance systemic circulation its wall
thickened and mass begin to increase.

 In contrast, the right ventricle is now coupled to

the low resistance pulmonary circulation its wall
thickened and mass decrease slightly.
 Foetal circulation: The left ventricle in the fetus
pumped blood only to the upper part of the body and
brain
 After birth: Left Ventricle must deliver the entire
systemic cardiac output (≈450 mL/kg/min). (almost
200% increase in output)

 This marked increase in left ventricular performance

is achieved through a combination of hormonal and
metabolic signals, including an INCREASE IN :
-The level of circulating catecholamines and
-The myocardial receptors (β-adrenergic)
(through which catecholamines have their
effect).
 When congenital structural cardiac defects are
superimposed on these dramatic physiologic
changes, they often impede this smooth transition
and markedly increase the burden on the newborn
myocardium.

 In addition, because the ductus arteriosus and

foramen ovale do not close completely at birth, they
may remain patent in certain congenital cardiac
lesions.
Patency of these foetal pathways may either :
 Provide a lifesaving pathway for blood to bypass a
congenital defect
 (eg: -Patent ductus in Pulmonary atresia or COA.
-Foramen ovale in Transposition of the great
vessels)
Or
 Present an additional stress to the circulation
(eg: -Patent ductus arteriosus in a premature infant,
-Rt to Lt shunt in infants with pulmonary
hypertension)
 Circulatory changes at birth

Shunt Functional Anatomical Remnant

closure closure

Ductus 10 – 15 hrs after 2– 3 wks after birth Ligamentum

arteriosus birth arteriosum

Formamen Within several One year after birth Fossa ovalis

ovale mins after birth

Ductus Within several 3 – 7 days after birth Ligamentum

venosus mins after birth venosum

Umbilical arteries → Umbilical ligaments

Umbilical vein → Ligamentum teres
 Clinical significances

Patent Ductus Arteriosus:

 Failure of a child's DA to close after birth
 generation of a left-to-right shunt as blood flows
from high pressure aorta to low pressure pulmonary
artery.
 Large shunt PDA may cause CHF and consequently
recurrent pneumonia. Pulmonary vascular
obstructive disease may develop if large PDA with
Pulmonary hypertension is left untreated
 Prostaglandins are responsible for maintaining the
ductus arteriosus by dilatation of the vascular
smooth muscles.
 Closure may be induced with NSAIDs because these
Patent foramen ovale:
 is an incomplete closure of the atrial septum that
results in the creation of a flap or a valve-like
opening in the atrial septal wall
 is present in everyone before birth but seals in
about 80% of people.
 With each heartbeat, blood can flow in either
direction directly between the right and left atrium.
 When blood moves directly from the right atrium to
the left atrium, this blood bypasses the filtering
system of the lungs.
 If large defect is untreated, CHF and Pulmonary
HTN may develop in 2nd or 3rd decade of life.
Thank you