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Doppler Fetal

Doppler Fetal

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02/03/2013

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 Doppler Evaluationof the Fetus
MICHAEL Y. DIVON, MD,
and 
ASAF FERBER, MD
 Department of Obstetrics and Gynecology, Lenox-Hill Hospital, New York, New York 
Doppler ultrasound is a noninvasive tech-niquethatiscommonlyusedtoevaluatema-ternal and fetal hemodynamics. This testingmodality is based on the premise that an in-sufficient uterine, placental, or fetal circula-tion results in an adverse pregnancy out-comeandthattheseabnormalitiescanbede-fined with the use of Doppler velocimetry.Doppler techniques have been used in ob-stetrics since the initial report of successfulrecording of blood flow signals from theumbilical artery by Fitzgerald and Drummin 1977.
1
Although Doppler velocimetry isthe newest modality to assess fetal well- being, it has been the subject of more ran-domized controlled trials than any other testof fetal well-being.
Uterine Artery Doppler 
Trophoblastinvasionintotheuterinevesselsoccurs early in the second trimester and re-sults in dilated spiral arteries, thus allowinga10-to12-foldincreaseinuterineperfusionand providing nutrient supply and gas ex-change to the fetus. The shape of the uterineartery velocity waveform is unique. It ischaracterized by high end-diastolic veloci-ties with continuous forward blood flowthroughout diastole. Typically, as gesta-tionalage(GA)advances,thedegreeofend-diastolic flow increases. Failure of tropho- blastic invasion of the spiral arteries resultsin increased vascular resistance of the uter-ine artery and decreased perfusion of the placenta and may subsequently result infetal growth restriction (FGR) and pre-eclampsia.
2,3
In normal pregnancies thesystolic/diastolic (S/D) ratio of the uterineartery should be less than 2.7 beyond the26th week of gestation. If the end-diastolicflow does not increase throughout preg-nancy or if a small notch is detected at theend of systole, the fetus is at high risk for developing FGR.
4
With extreme degrees of  placental dysfunction, diastolic blood flowmay be absent or even reversed. Such find-ings are ominous and may precede fetaldeath or signal a great risk of abnormal fetalneurologic outcome.IthasbeensuggestedthatDopplerstudiesof the uterine artery be performed early in pregnancy for screening purposes. Camp- bell et al
5
 performed a cohort study in agroupof126consecutivepregnancies.Theyevaluated Doppler velocimetry studies of the uterine artery as a predictor of preg-
Correspondence: Michael Y. Divon, MD, Department of Obstetrics and Gynecology, Lenox-Hill Hospital,100 E. 77th St. New York, NY 10021. E-mail: divon@lenoxhill.net 
CLINICALOBSTETRICSANDGYNECOLOGY
Volume 45, Number 4, 1015–1025© 2002, Lippincott Williams & Wilkins, Inc.
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 45 / NUMBER 4 / DECEMBER 2002
1015
 
nancy-induced hypertension (PIH), FGR, or fetal asphyxia. The sensitivity, specificity,and positive and negative predictive valueswere 68%, 69%, 42%, and 87%, respec-tively. In a prospective cross-sectional trial,Zimmermann et al
6
studied 175 pregnantwomenathighriskfordevelopinghyperten-sionorFGR,andacontrolgroupof172low-risk pregnancies at 21 to 24 weeks’ gesta-tion. Persistent notching of the mainstemuterine arteries or elevated resistance indi-ces of more than 0.68 in the uterine arteriesandmorethan0.38inuteroplacentalarterieswere defined as abnormal studies. In thehigh-risk group, PIH and/or FGR werefound in 58.3% if the Doppler studies wereabnormal, compared with 8.3% for normalDoppler studies. Doppler was far less pre-dictive in the low-risk population. In thisgroup, PIH and/or FGR were present in ap- proximately 6% of the patients with abnor-mal Doppler findings, compared with a 5%incidence detected in pregnancies with nor-mal findings. Chien et al
7
reviewed the util-ityofDopplerstudiesoftheuterinearteryinthe prediction of preeclampsia and its asso-ciated complications, such as FGR and peri-nataldeath.Theyperformedameta-analysisof 27 published and unpublished observa-tionalstudiesinvolving12,994pregnancies.These pregnancies were stratified into low-or high-risk categories for developing pre-eclampsia and its complications. The resultsof this study are shown in Table 1. Based onthese results, the authors concluded thatuterine artery Doppler flow velocimetry haslimited diagnostic accuracy in predicting preeclampsia, FGR, and perinatal death.Most recently, Papageorghiou et al
8
con-ducted a multicenter, cohort study to deter-mine the utility of transvaginal color Dopp-ler assessment of the uterine arteries at 23weeks’ gestation in the prediction of pre-eclampsia and FGR (defined as birthweight below the 10th percentile for GA). A mean pulsatilityindexof1.63(the95thpercentile)ormoreorbilateralnotchingwasconsidered abnormal.In932(11.9%)ofthe7,851study patients, at least one of these abnormalitieswas documented. The sensitivity, specific-ity,andpositiveandnegativepredictiveval-ues of an abnormal test were 83.3%, 88.5%,3.8%, and 99.9%, respectively, with a like-lihood ratio of 7.3 (95% confidence interval[CI] 6.0–8.2). Furthermore, the sensitivitywas inversely related to the GA at delivery(ie, the sensitivity increased as GA at deliv-ery decreased). However, the sensitivities inthe prediction of either preeclampsia with-outFGRorFGRwithoutpreeclampsiaweremuch lower (40.8% and 24.4%, respec-tively). In addition, when only one of theuterine artery Doppler characteristics wasabnormal (either pulsatility index or bilat-eralnotching),thesensitivitiesinthepredic-tion of either one of the two outcomes werelower. Based on these results, the authorssuggested that uterine artery Doppler screeningat23weeksismuchbetteratiden-tifying the more severe and therefore mostclinicallyrelevantcasesofpreeclampsiaand FGR. The authors concluded that their find-ingsdemonstratedthefeasibilityofincorpo-rating Doppler assessment of the uterine ar-teriesintotheroutinesecond-trimesterscan.In a subsequent study, these authors evalu-
TABLE 1. Likelihood Ratios (and 95% Confidence Intervals) for Uterine Artery Doppler Velocimetry
Low-Risk Pregnancies High-Risk PregnanciesAbnormal Test Normal Test Abnormal Test Normal Test
Preeclampsia 6.4 (5.77.1) 0.7 (0.60.8) 2.8 (2.33.4) 0.8 (0.70.9)Fetal growth restriction 3.6 (3.24.0) 0.8 (0.80.9) 2.8 (2.13.4) 0.7 (0.60.9)Perinatal death 1.8 (1.22.9) 0.9 (0.81.1) 4.0 (2.46.6) 0.6 (0.40.9)
Modified from Chien et al.
7
1016
DIVON AND FERBER 
 
ated the characteristics of uterine artery PIusing transvaginal color Doppler.
9
Theydemonstrated that in 95% of studies, the in-traobserverandinterobservervariabilityand waveform tracing repeatability were lessthan 0.24, 0.27, and 0.14, respectively.Overall, there is a lack of randomized,controlled trials of the utility of uterine ar-tery Doppler studies in the screening of  pregnancy complications such as pre-eclampsia or FGR. Therefore, it would not be prudent to recommend the general use of umbilical artery Doppler velocimetry as ageneral screening modality.
Umbilical Artery Doppler 
Longitudinal Doppler studies of the umbili-cal artery show that the S/D ratio decreasesas GA increases (as a indirect reflection of the decreasing placental impedance).
10
There is no clear-cut agreement as to whatconstitutes an abnormal Doppler study.Most authors have used an S/D ratio greater than3.0asanabnormaltestresultbeyond30weeks
gestation.
11
Evidence from clinicalexperience and randomized controlled trialsshows a significant association between ab-normal umbilical artery Doppler velocim-etry and an adverse perinatal outcome.
12
PLACENTAL LESIONS
Abnormal umbilical artery velocity wave-forms have been associated with specificmorphologic lesions of the placenta.
11
Ab-sent end-diastolic flow is characterized bymedial hyperplasia and luminal obliterationof fetal stem vessels, whereas reversed end-diastolic flow is characterized by poorlyvascularized terminal villi, villous stromalhemorrhage, hemorrhagic endovasculitis,and abnormally thin-walled fetal stem ves-sels.
13,14
Inaddition,placentaswithpositiveend-diastolic flow demonstrate more gas-exchanging villi than those with absent or reversed end-diastolic flow.
15
The gas-exchangingvillifromthelatterplacentasareslender, elongated, poorly branched, and  poorly capillarized.
FETAL GROWTH RESTRICTION
Many investigators have reported on the as-sociation of abnormal umbilical artery ve-locity waveforms with FGR. As the S/D ra-tio increases, the birth weight for GA per-centile decreases. In one study of 127 pregnancies, the sensitivity, specificity, and  positive predictive value of an S/D ratio of more than 3.0 for identifying FGR were49%,94%,and81%,respectively.
16
Similar results were documented by other investiga-tors.
17,18
DIFFERENTIATING THEGROWTH-RESTRICTED FETUSFROM THE CONSTITUTIONALLYSMALL FETUS
 Not all infants whose birthweight is belowthe 10th percentile have been exposed to a pathologic process in utero; in fact, mostsmall newborns are constitutionally smalland healthy. Differentiating the fetus with pathologic growth restriction that is at risk for perinatal complications from the consti-tutionally small but healthy fetus has beenan ongoing challenge in obstetrics.An umbilical artery Doppler study of 308fetuses with either an ultrasonographicweight estimate less than the 10th percentileor an abdominal circumference less than the2.5th percentile for GA detected 138 fetuseswho also had elevated umbilical artery S/Dratios (>90th percentile for GA).
19
Abnor-mal Doppler studies were associated withlower arterial and venous pH values, an in-creased likelihood of intrapartum fetal dis-tress,moreadmissionstotheneonatalinten-sive care unit, and a higher incidence of re-spiratory distress syndrome. The likelihood of a false-positive diagnosis of FGR was in-creased in the group with normal umbilicalarteryDopplerstudies.NofetuswithnormalDoppler flow measurements was delivered with metabolic acidemia associated withchronic hypoxemia. The authors suggested that antenatal surveillance is unnecessary infetuses with suspected FGR if the umbilicalartery Doppler studies are normal. Othershave confirmed that small fetuses with nor-
 Doppler Evaluation of the Fetus
1017

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