ated the characteristics of uterine artery PIusing transvaginal color Doppler.
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).
There is no clear-cut agreement as to whatconstitutes an abnormal Doppler study.Most authors have used an S/D ratio greater than3.0asanabnormaltestresultbeyond30weeks
Evidence from clinicalexperience and randomized controlled trialsshows a significant association between ab-normal umbilical artery Doppler velocim-etry and an adverse perinatal outcome.
Abnormal umbilical artery velocity wave-forms have been associated with specificmorphologic lesions of the placenta.
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.
Inaddition,placentaswithpositiveend-diastolic flow demonstrate more gas-exchanging villi than those with absent or reversed end-diastolic flow.
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.
Similar results were documented by other investiga-tors.
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).
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