Fetal Circulation

In the fetal circulation, the right and left ventricles exist in a parallel circuit, as opposed to the series
circuit of a newborn or adult. In the fetus, the placenta provides for gas and metabolite exchange. The
lungs do not provide gas exchange, and vessels in the pulmonary circulation are vasoconstricted. Three
cardiovascular structures unique to the fetus are important for maintaining this parallel circulation: the
ductus venosus, foramen ovale, and ductus arteriosus.

Oxygenated blood returning from the placenta flows to the fetus through the umbilical vein with
a PO2 of about 3035mmHg. Approximately 50% of the umbilical venous blood enters the
hepatic circulation, whereas the rest bypasses the liver and joins the inferior vena cava via the
ductus venosus, where it partially mixes with poorly oxygenated inferior vena cava blood derived
from the lower part of the fetal body. This combined lower body plus umbilical venous blood
flow (PO2 of about 2628mmHg) enters 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.
Fetal superior vena cava blood, which is considerably less oxygenated (P O2 of 1214mmHg),
enters the right atrium and preferentially traverses the tricuspid valve, rather than the foramen
ovale, and flows primarily to the right ventricle.
 From the right ventricle, the blood is ejected into the pulmonary artery. Because the pulmonary
arterial circulation is vasoconstricted, only about 10% of right ventricular outflow enters the
lungs.
The major portion of this blood (which has a P O2 of about 1822mmHg) bypasses the lungs and
flows through the ductus arteriosus into the descending aorta to perfuse the lower part of the
fetal body, after which it returns to the placenta via the two umbilical arteries. Thus, the upper
part of the fetal body (including the coronary and cerebral arteries and those to the 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 fetal body, which is derived mostly from the
right ventricle. Only a small volume of blood from the ascending aorta (10% of fetal cardiac
output) flows across the aortic isthmus to the descending aorta.

The total fetal cardiac outputthe combined ventricular output of both the left and right
ventriclesamounts to about 450mL/kg/min. Approximately 65% of descending aortic blood
flow returns to the placenta; the remaining 35% perfuses the fetal organs and tissues. In the
sheep fetus, right ventricular output is approximately two times that of the left ventricle. In the
human fetus, which has a larger percentage of blood flow going to the brain, right ventricular
output is probably closer to 1.3 times left ventricular flow. Thus, during fetal life the right
ventricle is not only pumping against systemic blood pressure but is also performing a greater
volume of work than the left ventricle is.

Circulation Change At Birth

Changes in the vascular system at birth are caused by cessation of placental blood flow and the
beginning of respiration. Since the ductus arteriosus closes by muscular contraction of its wall,
the amount of blood flowing through the lung vessels increases rapidly. This, in turn, raises
pressure in the left atrium. Simultaneously, pressure in the right atrium decreases as a result of
interruption of placental blood flow. The septum primum is then apposed to the septum
secundum, and functionally the oval foramen closes.

a) Closure of the umbilical arteries, accomplished by contraction of the smooth musculature in

their walls, is probably caused by thermal and mechan- ical stimuli and a change in oxygen
tension. Functionally the arteries close a few minutes after birth, although the actual obliteration
of the lumen by brous proliferation may take 2 to 3 months. Distal parts of the umbilical
arteries form the medial umbilical ligaments, and the proximal portions remain open as the
superior vesical arteries.
b) Closure of the umbilical vein and ductus venosus occurs shortly after that of the umbilical
arteries. Hence blood from the placenta may enter the newborn for some time after birth. After
obliteration, the umbilical vein forms the ligamentum teres hepatis in the lower margin of the
falciform ligament. The ductus venosus, which courses from the ligamentum teres to the inferior
vena cava, is also obliterated and forms the ligamentum venosum.
c) Closure of the ductus arteriosus by contraction of its muscular wall occurs almost immediately
after birth; it is mediated by bradykinin, a substance re- leased from the lungs during initial
inflation. Complete anatomical obliteration by proliferation of the intima is thought to take 1 to 3
months. In the adult the obliterated ductus arteriosus forms the ligamentum arteriosum.
d) Closure of the oval foramen is caused by an increased pressure in the left atrium, combined with
a decrease in pressure on the right side. The rst breath presses the septum primum against the
septum secundum. During the rst days of life, however, this closure is reversible. Crying by the
baby creates a shunt from right to left, which accounts for cyanotic periods in the newborn.
Constant apposition gradually leads to fusion of the two septa in about 1 year. In 20% of
individuals, however, perfect anatomical closure may never be obtained (probe patent foramen
ovale).