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. 2025 Aug 5;25(1):811.
doi: 10.1186/s12884-025-07985-3.

Prognostic value of foramen ovale morphology and hemodynamics in late-onset fetal growth restriction: a 3D ultrasonography-based study

Özgür Volkan Akbulut  1 , Recep Taha Ağaoğlu  2 , Can Ozan Ulusoy  1 , Aziz Kından  1 , Kubilay Çanga  1 , Zehra Vural Yılmaz  1
Affiliations

Prognostic value of foramen ovale morphology and hemodynamics in late-onset fetal growth restriction: a 3D ultrasonography-based study

Özgür Volkan Akbulut et al. BMC Pregnancy Childbirth. .

Abstract

Objective: To assess the structural and hemodynamic characteristics of the foramen ovale (FO) in fetuses with late-onset fetal growth restriction (LO-FGR) using three-dimensional (3D) ultrasonography and Doppler imaging, and to examine their associations with Doppler parameters in FGR and composite adverse perinatal outcomes (CAPO).

Methods: This case-control study included 40 fetuses with LO-FGR and 40 matched controls exhibiting appropriate-for-gestational-age (AGA) between 34 and 37 weeks. FO area was measured using 3D spatio-temporal image correlation (STIC) imaging, and FO width and pulsatility index (PI) were evaluated using 2D and Doppler ultrasonography. FO parameters were compared between the groups, and partial correlation analyses adjusted for gestational age to assess their associations with FGR and CAPO. Additionally, Receiver Operating Characteristic (ROC) curve analysis was conducted to evaluate the predictive value of FO parameters for CAPO within the FGR group.

Results: FO area (p < 0.001), FO width (p < 0.001), left atrial (LA) width (p = 0.029), FO/LA ratio (p < 0.001), and FO/RA ratio (p = 0.024) were significantly reduced in the FGR group compared to the controls. Among FGR fetuses, those who developed CAPO had lower FO area (p = 0.009), FO width (p = 0.001), LA width (p = 0.006), FO/LA ratio (p < 0.001), and FO/RA ratio (p = 0.041). In ROC analysis, the FO/LA ratio exhibited the highest predictive value for predicting CAPO (AUC: 0.851, p < 0.001).

Conclusion: Alterations in FO morphology are significantly associated with adverse perinatal outcomes in LO-FGR. The FO/LA ratio may serve as a reliable and noninvasive parameter for risk stratification. Incorporating advanced fetal cardiac morphometry could improve prenatal surveillance in FGR.

Keywords: Composite adverse perinatal outcome; Fetal growth restriction; Fetal hemodynamics; Foramen ovale; Three-dimensional ultrasonography.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study protocol was approved by the Ankara Etlik City Hospital Ethics Committee (approval number: AESH-BADEK-2025-0074). and written informed consent was obtained from all participants. The study adhered to the ethical principles outlined in the Declaration of Helsinki. Consent for publication: Not applicable. This study does not contain any individual person’s data in any form (including any individual details, images, or videos) that would require consent for publication. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Measurement of Right and Left Atrial Widths in the Four-Chamber View. Ultrasound image illustrating the measurement of maximal transverse diameters of the left atrium (LA) and right atrium (RA) in a lateral four-chamber view
Fig. 2
Fig. 2
Three-dimensional Spatiotemporal Image Correlation (STIC) image showing the measurement of the foramen ovale (FO) area. The contour of the FO area was manually traced on the plane providing optimal visualization for area calculation
Fig. 3
Fig. 3
Two-dimensional ultrasound image illustrating the measurement of foramen ovale (FO) width from the most prominent point of the foramen ovale flap (FOF) to the interatrial septum
Fig. 4
Fig. 4
Receiver Operating Characteristic (ROC) Curves of Foramen Ovale Morphometric and Doppler Parameters for Predicting Composite Adverse Perinatal Outcomes (CAPO) in Fetuses With Fetal Growth Restriction
See this image and copyright information in PMC

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