ANATOMY
Anatomy of fetal circulation
Harold Ellis
The circulation of the blood in the fetus is a remarkable example
of the economy of nature in the shunting of well-oxygenated blood
from the placenta to the brain, leaving relatively desaturated blood
to supply less essential structures.
Deoxygenated blood passes to the placenta via the umbilical
arteries, which arise from the right and left internal iliac arteries.
Fetal blood is oxygenated in the placenta and returns to the fetus
via the umbilical veins. Initially these veins are double (a right
and a left) and empty into the hepatic venous sinusoids, but early
in fetal life the right vein regresses completely. The persistent
left umbilical vein, which passes from the umbilicus to the liver
along the free edge of the falciform ligament, empties into the left
branch of the portal vein. From here there is a direct shunt, via
the ductus venosus, into the inferior vena cava, and thence into
the right atrium (Figure 1).
Relatively little mixing of oxygenated and deoxygenated blood
takes place in the right atrium, because the valve (crista termi-
nalis) overlying the termination of the inferior vena cava deflects
the flow of oxygenated blood from that vessel through the next
shunt in the fetal circulation (the foramen ovale) into the left
atrium, while the deoxygenated stream from the superior vena
cava is directed through the tricuspid valve into the right ventricle.
From the left atrium, the oxygenated blood, together with a small
amount of deoxygenated blood from the lungs draining to the left
atrium through the pulmonary veins, passes into the left ventricle
through the mitral valve and thence into the ascending aorta to
supply the heart muscle, via the coronary arteries, and the brain,
via the vertebral and carotid arteries.
As the lungs of the fetus are inactive, most of the deoxygenated
blood from the right ventricle is diverted via the third shunt, the
ductus arteriosus (which is almost the size of the aorta) from the
pulmonary trunk into the descending aorta, distal to the origins of
the cerebral arterial blood flow. This blood supplies the abdominal
viscera and lower limbs and is shunted, via the umbilical arteries,
to the placenta for oxygenation. At birth, expansion of the lungs
leads to a massive increase in blood flow in the pulmonary arter-
ies. The uncoiling of the fetal pulmonary blood vessels results in
a sudden considerable fall in pulmonary vascular resistance, while
at the same time the systemic circulation increases. Thus, there is
Harold Ellis was Professor of Surgery at Westminster Medical School, UK,
until 1989. Since then he has taught anatomy, first in Cambridge and
now at Guy’s Hospital, London, UK.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 6:3
The fetal circulation
Left subclavian artery
Left common carotid artery
Brachiocephalic artery
Ductus arteriosus
Right pulmonary artery
Aorta
Left pulmonary
artery
Superior vena cava
Septum II
Foramen ovale
Septum I
Pulmonary trunk
Aorta
Inferior vena cava
Umbilical arteries
The red arrows denote oxygenated blood
Reproduced with permission from Ellis H, Feldman S, Harrop-Griffiths W.
Anatomy for anaesthetists. 8th ed. Oxford: Blackwell Publishing, 2004.
1
a fall in pressure in the right atrium and a rise in the left, bringing
the septum primum and septum secundum of the foramen ovale
together, effectively closing the shunt.
At the same time, contraction of the muscular wall of the
ductus arteriosus results in functional closure of the shunt,
which completely obliterates over the next two or three months.
Similarly, ligation and division of the umbilical cord is followed
by thrombosis of the umbilical vessels, though immediately after
birth these vessels are readily available for cannulation for blood
samples and for transfusion.
In adult anatomy the following remains of the fetal circulation
can be readily recognized.
• The medial umbilical ligament on each side, passing from the
superior vesical branch of the internal iliac artery to the umbilicus,
represents the obliterated umbilical arteries.
• The round ligament, or ligamentum teres, lying in the free edge
of the falciform ligament and then in its groove on the under-
surface of the liver, represents the obliterated umbilical vein.
• The ligamentum venosum, lying within its fissure on the
undersurface of the liver, continuing the ligamentum teres and
terminating at the inferior vena cava, represents the obliterated
ductus venosus.
• The fossa ovalis on the interatrial septum, which is ‘probe
patent’ in about 10% of normal subjects, represents the foramen
ovale.
• The ligamentum arteriosum, between the aortic arch and the
left pulmonary artery, with the recurrent laryngeal nerve in close
proximity, represents the ductus arteriosus. u
73 © 2005 The Medicine Publishing Company Ltd