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CLINICAL OBSTETRICS AND GYNECOLOGY


Volume 45, Number 4, 1015–1025
© 2002, Lippincott Williams & Wilkins, Inc.

Doppler Evaluation
of 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- artery velocity waveform is unique. It is


nique that is commonly used to evaluate ma- characterized by high end-diastolic veloci-
ternal and fetal hemodynamics. This testing ties with continuous forward blood flow
modality is based on the premise that an in- throughout diastole. Typically, as gesta-
sufficient uterine, placental, or fetal circula- tional age (GA) advances, the degree of end-
tion results in an adverse pregnancy out- diastolic flow increases. Failure of tropho-
come and that these abnormalities can be de- blastic invasion of the spiral arteries results
fined with the use of Doppler velocimetry. in increased vascular resistance of the uter-
Doppler techniques have been used in ob- ine artery and decreased perfusion of the
stetrics since the initial report of successful placenta and may subsequently result in
recording of blood flow signals from the fetal growth restriction (FGR) and pre-
umbilical artery by Fitzgerald and Drumm eclampsia.2,3 In normal pregnancies the
in 1977.1 Although Doppler velocimetry is systolic/diastolic (S/D) ratio of the uterine
the newest modality to assess fetal well- artery should be less than 2.7 beyond the
being, it has been the subject of more ran- 26th week of gestation. If the end-diastolic
domized controlled trials than any other test flow does not increase throughout preg-
of fetal well-being. nancy or if a small notch is detected at the
end of systole, the fetus is at high risk for
developing FGR.4 With extreme degrees of
Uterine Artery Doppler placental dysfunction, diastolic blood flow
Trophoblast invasion into the uterine vessels may be absent or even reversed. Such find-
occurs early in the second trimester and re- ings are ominous and may precede fetal
sults in dilated spiral arteries, thus allowing death or signal a great risk of abnormal fetal
a 10- to 12-fold increase in uterine perfusion neurologic outcome.
and providing nutrient supply and gas ex- It has been suggested that Doppler studies
change to the fetus. The shape of the uterine of the uterine artery be performed early in
pregnancy for screening purposes. Camp-
bell et al5 performed a cohort study in a
Correspondence: Michael Y. Divon, MD, Department group of 126 consecutive pregnancies. They
of Obstetrics and Gynecology, Lenox-Hill Hospital,
100 E. 77th St. New York, NY 10021. E-mail: divon@ evaluated Doppler velocimetry studies of
lenoxhill.net the uterine artery as a predictor of preg-

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 45 / NUMBER 4 / DECEMBER 2002

1015
1016 DIVON AND FERBER

nancy-induced hypertension (PIH), FGR, or Most recently, Papageorghiou et al8 con-


fetal asphyxia. The sensitivity, specificity, ducted a multicenter, cohort study to deter-
and positive and negative predictive values mine the utility of transvaginal color Dopp-
were 68%, 69%, 42%, and 87%, respec- ler assessment of the uterine arteries at 23
tively. In a prospective cross-sectional trial, weeks’ gestation in the prediction of pre-
Zimmermann et al6 studied 175 pregnant eclampsia and FGR (defined as birthweight
women at high risk for developing hyperten- below the 10th percentile for GA). A mean
sion or FGR, and a control group of 172 low- pulsatility index of 1.63 (the 95th percentile)
risk pregnancies at 21 to 24 weeks’ gesta- or more or bilateral notching was considered
tion. Persistent notching of the mainstem abnormal. In 932 (11.9%) of the 7,851 study
uterine arteries or elevated resistance indi- patients, at least one of these abnormalities
ces of more than 0.68 in the uterine arteries was documented. The sensitivity, specific-
and more than 0.38 in uteroplacental arteries ity, and positive and negative predictive val-
were defined as abnormal studies. In the ues of an abnormal test were 83.3%, 88.5%,
high-risk group, PIH and/or FGR were 3.8%, and 99.9%, respectively, with a like-
found in 58.3% if the Doppler studies were lihood ratio of 7.3 (95% confidence interval
abnormal, compared with 8.3% for normal [CI] 6.0–8.2). Furthermore, the sensitivity
Doppler studies. Doppler was far less pre- was inversely related to the GA at delivery
dictive in the low-risk population. In this (ie, the sensitivity increased as GA at deliv-
group, PIH and/or FGR were present in ap- ery decreased). However, the sensitivities in
proximately 6% of the patients with abnor- the prediction of either preeclampsia with-
mal Doppler findings, compared with a 5% out FGR or FGR without preeclampsia were
incidence detected in pregnancies with nor- much lower (40.8% and 24.4%, respec-
mal findings. Chien et al7 reviewed the util- tively). In addition, when only one of the
ity of Doppler studies of the uterine artery in uterine artery Doppler characteristics was
the prediction of preeclampsia and its asso- abnormal (either pulsatility index or bilat-
ciated complications, such as FGR and peri- eral notching), the sensitivities in the predic-
natal death. They performed a meta-analysis tion of either one of the two outcomes were
of 27 published and unpublished observa- lower. Based on these results, the authors
tional studies involving 12,994 pregnancies. suggested that uterine artery Doppler
These pregnancies were stratified into low- screening at 23 weeks is much better at iden-
or high-risk categories for developing pre- tifying the more severe and therefore most
eclampsia and its complications. The results clinically relevant cases of preeclampsia and
of this study are shown in Table 1. Based on FGR. The authors concluded that their find-
these results, the authors concluded that ings demonstrated the feasibility of incorpo-
uterine artery Doppler flow velocimetry has rating Doppler assessment of the uterine ar-
limited diagnostic accuracy in predicting teries into the routine second-trimester scan.
preeclampsia, FGR, and perinatal death. 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 Pregnancies
Abnormal Test Normal Test Abnormal Test Normal Test
Preeclampsia 6.4 (5.7–7.1) 0.7 (0.6–0.8) 2.8 (2.3–3.4) 0.8 (0.7–0.9)
Fetal growth restriction 3.6 (3.2–4.0) 0.8 (0.8–0.9) 2.8 (2.1–3.4) 0.7 (0.6–0.9)
Perinatal death 1.8 (1.2–2.9) 0.9 (0.8–1.1) 4.0 (2.4–6.6) 0.6 (0.4–0.9)
Modified from Chien et al.7
Doppler Evaluation of the Fetus 1017

ated the characteristics of uterine artery PI FETAL GROWTH RESTRICTION


using transvaginal color Doppler.9 They Many investigators have reported on the as-
demonstrated that in 95% of studies, the in- sociation of abnormal umbilical artery ve-
traobserver and interobserver variability and locity waveforms with FGR. As the S/D ra-
waveform tracing repeatability were less tio increases, the birth weight for GA per-
than 0.24, 0.27, and 0.14, respectively. centile decreases. In one study of 127
Overall, there is a lack of randomized, pregnancies, the sensitivity, specificity, and
controlled trials of the utility of uterine ar- positive predictive value of an S/D ratio of
tery Doppler studies in the screening of more than 3.0 for identifying FGR were
pregnancy complications such as pre- 49%, 94%, and 81%, respectively.16 Similar
eclampsia or FGR. Therefore, it would not results were documented by other investiga-
be prudent to recommend the general use of tors.17,18
umbilical artery Doppler velocimetry as a
general screening modality.
DIFFERENTIATING THE
GROWTH-RESTRICTED FETUS
FROM THE CONSTITUTIONALLY
Umbilical Artery Doppler SMALL FETUS
Longitudinal Doppler studies of the umbili- Not all infants whose birthweight is below
cal artery show that the S/D ratio decreases the 10th percentile have been exposed to a
as GA increases (as a indirect reflection of pathologic process in utero; in fact, most
the decreasing placental impedance). 10 small newborns are constitutionally small
There is no clear-cut agreement as to what and healthy. Differentiating the fetus with
constitutes an abnormal Doppler study. pathologic growth restriction that is at risk
Most authors have used an S/D ratio greater for perinatal complications from the consti-
than 3.0 as an abnormal test result beyond 30 tutionally small but healthy fetus has been
weeks’ gestation.11 Evidence from clinical an ongoing challenge in obstetrics.
experience and randomized controlled trials An umbilical artery Doppler study of 308
shows a significant association between ab- fetuses with either an ultrasonographic
normal umbilical artery Doppler velocim- weight estimate less than the 10th percentile
etry and an adverse perinatal outcome.12 or an abdominal circumference less than the
2.5th percentile for GA detected 138 fetuses
PLACENTAL LESIONS who also had elevated umbilical artery S/D
Abnormal umbilical artery velocity wave- ratios (>90th percentile for GA).19 Abnor-
forms have been associated with specific mal Doppler studies were associated with
morphologic lesions of the placenta.11 Ab- lower arterial and venous pH values, an in-
sent end-diastolic flow is characterized by creased likelihood of intrapartum fetal dis-
medial hyperplasia and luminal obliteration tress, more admissions to the neonatal inten-
of fetal stem vessels, whereas reversed end- sive care unit, and a higher incidence of re-
diastolic flow is characterized by poorly spiratory distress syndrome. The likelihood
vascularized terminal villi, villous stromal of a false-positive diagnosis of FGR was in-
hemorrhage, hemorrhagic endovasculitis, creased in the group with normal umbilical
and abnormally thin-walled fetal stem ves- artery Doppler studies. No fetus with normal
sels.13,14 In addition, placentas with positive Doppler flow measurements was delivered
end-diastolic flow demonstrate more gas- with metabolic acidemia associated with
exchanging villi than those with absent or chronic hypoxemia. The authors suggested
reversed end-diastolic flow. 15 The gas- that antenatal surveillance is unnecessary in
exchanging villi from the latter placentas are fetuses with suspected FGR if the umbilical
slender, elongated, poorly branched, and artery Doppler studies are normal. Others
poorly capillarized. have confirmed that small fetuses with nor-
1018 DIVON AND FERBER

mal umbilical artery Doppler studies are end-diastolic flow, the likelihood of chro-
more likely to be constitutionally small and mosomal anomalies is sufficiently low to
healthy rather than growth-restricted and forgo a genetic study. Furthermore, several
sick.20,21 authors have suggested that genetic studies
By comparison, conflicting data were should be performed in fetuses with abnor-
presented in a study that prospectively mal umbilical artery Doppler studies de-
evaluated 186 FGR fetuses.22 Abnormal tected at 10 to 18 weeks’ gestation.24,25
umbilical artery Doppler studies (n = 77)
were associated with a diagnosis of FGR PERINATAL OUTCOME
earlier in pregnancy, smaller ponderal indi- Numerous randomized controlled trials
ces, and an increased likelihood of neonatal have shown that abnormal umbilical artery
morbidity and mortality. However, an ab- velocity waveforms are valuable in identify-
normal umbilical artery Doppler study was ing the growth-restricted fetus at increased
not an independent predictor of a prolonged risk for one or more of the following out-
newborn nursery stay or hypoglycemia comes: early delivery, reduced birthweight,
when birthweight and GA were added to the oligohydramnios, neonatal intensive care
logistic regression model. In addition, 49% unit admission, and prolonged hospital
of small-for-GA fetuses with normal umbili- stay.26,27 A meta-analysis of randomized
cal artery Doppler studies (n = 109) had ab- controlled trials on the use of Doppler so-
normally low ponderal indices, 26% were nography in pregnancies complicated by
hypoglycemic at birth, and 35% required ad- suspected FGR reported that using this tech-
mission to the neonatal intensive care unit. nology resulted in a statistically significant
The authors confirmed that abnormal um- improvement in perinatal outcome, includ-
bilical artery Doppler studies are associated ing a 38% reduction in perinatal mortality.26
with a poor outcome but also concluded that A subsequent Cochrane review27 of 11 trials
the perinatal outcome in small fetuses with consisting of 7,000 high-risk pregnancies
normal Doppler studies is not always be- randomly assigned to Doppler versus non-
nign. Doppler ultrasound studies found that
Doppler ultrasound was associated with a
CHROMOSOMAL ABNORMALITIES trend toward a reduction in perinatal death
Rizzo et al23 evaluated 192 singleton preg- (odds ratio [OR] 0.71, 95% CI 0.50–1.01),
nancies with absent end-diastolic velocity in especially in pregnancies complicated by
the umbilical artery and available fetal hypertension or presumed FGR. The use of
karyotype. The mean GA was 28.3 ± 3.3 Doppler ultrasound was also associated with
weeks. Sixteen fetuses (8.3%) had an abnor- fewer inductions of labor (OR 0.83, 95% CI
mal karyotype: nine cases of trisomy 18, 0.74–0.93) and fewer hospital admissions
four cases of trisomy 21, two cases of trip- (OR 0.56, 95% CI 0.43–0.72), without re-
loidy (69,XXX), and one case of 46XY, ports of adverse perinatal effects. No differ-
(del) 4p. GA at diagnosis of absent end- ences were found in the rates of intrapartum
diastolic velocity in the umbilical artery was fetal distress or cesarean delivery. The re-
significantly lower in the chromosomally viewers concluded that the use of Doppler
abnormal fetuses. In addition, structural studies is likely to reduce perinatal death
anomalies were more frequent in fetuses rates in high-risk pregnancies. However, the
with chromosomal aberrations. The authors utility of these techniques in low-risk preg-
felt that rapid acquisition of fetal karyotype nancies was not addressed by the study. An
is mandatory in fetuses with umbilical artery American College of Obstetricians and Gy-
absent end-diastolic velocity and congenital necologists committee opinion on the utility
anomalies. However, we believe that when of antepartum umbilical artery Doppler ve-
maternal hypertension is associated with no locimetry in FGR also concluded that an ab-
Doppler Evaluation of the Fetus 1019

normal test result identifies early fetal com- 0.50–1.60), nor was there any significant ef-
promise, thus allowing for the formulation fect on stillbirths (global OR 0.94; 95% CI
of appropriate management plans.12 0.42–1.98). On the basis of the results of
the published trials and their own meta-
LONG-TERM NEUROLOGIC OUTCOME analysis, they concluded that routine use of
Valcamonico et al28 evaluated the associa- umbilical artery Doppler studies in low-risk
tion of umbilical artery Doppler velocimetry patients is unlikely to be beneficial.30 Simi-
with long-term neurologic outcome in a co- larly, Bricker and Neilson31 reviewed the lit-
hort of growth-restricted fetuses with nor- erature to assess the effects on the practice of
mal (n = 17), reduced (n = 23), and absent or obstetrics and pregnancy outcome of routine
reversed (n = 31) umbilical artery end- Doppler ultrasound use in unselected and
diastolic flow. The infants who survived the low-risk pregnancies. Five trials were in-
neonatal period were observed for a mean of cluded (n = 14,338 women). The authors re-
18 months (range 12–24 months). Their pos- ported in the Cochrane Library that based on
tural, sensorial, and cognitive functions existing evidence, routine Doppler ultra-
were evaluated at 3, 6, 9, 12, and 18 months sound in low-risk or unselected populations
of age. The authors demonstrated that the in- does not confer benefit on mother or new-
cidence of permanent neurologic sequelae born.
increased as the umbilical artery end-
diastolic flow decreased (35% with absent
or reversed flow, 12% with reduced flow, INTRAPARTUM UMBILICAL ARTERY
and 0% with normal flow). However, due to DOPPLER STUDIES
the small study population, these differences Farrel et al 32 reviewed the literature to
did not reach statistical significance. Re- evaluate the diagnostic predictive value of
cently, Wienerroither et al29 followed 23 intrapartum umbilical artery Doppler veloc-
growth-restricted fetuses that had umbilical imetry for adverse perinatal outcome. Eight
artery absent or reversed end-diastolic ve- studies with a total of 2,700 pregnancies of
locities and a matched group of fetuses with mixed obstetric risk populations were se-
appropriate growth. All children were fol- lected for meta-analysis. Outcome measures
lowed for approximately 6 years. Intellec- included Apgar scores less than 7 at 1 and 5
tual development was significantly better in minutes, small for GA, intrapartum fetal
the control group compared with the study heart rate abnormalities, umbilical arterial
group. Likewise, neuromotor function was acidosis, and cesarean section for fetal dis-
significantly diminished in fetuses with ab- tress. The prediction of these outcomes was
normal Doppler studies. There were no de- disappointing, and the authors concluded
tectable differences in social development. that intrapartum umbilical artery Doppler
velocimetry is a poor predictor of adverse
LOW-RISK PREGNANCIES perinatal outcome.32
Goffinet et al30 published a meta-analysis of In summary, it is clear that growth-
the use of umbilical artery Doppler velocim- restricted fetuses with abnormal umbilical
etry in low-risk, unselected pregnancies. A artery Doppler velocimetry are exposed to
total of 11,375 pregnancies were assessed in higher odds of adverse perinatal outcome.
four randomized controlled trials. System- Thus, intensive monitoring (eg, nonstress
atic use of Doppler umbilical artery veloc- test, biophysical profile, serial Doppler and
imetry had no statistically detectable effect sonographic examinations) and possible in-
on perinatal deaths in unselected popula- tervention (eg, antenatal corticosteroids,
tions (OR 1.28; 95% CI 0.61–2.67), low-risk early delivery) as well as genetic studies
populations (OR 051; 95% CI 0.20–1.29), or may be required. In contrast, the data sug-
overall for the four trials (OR 0.90; 95% CI gest that there is no benefit in using umbili-
1020 DIVON AND FERBER

cal artery Doppler velocimetry screening in 2.1, 95% CI 1.1–4.3) if cerebral velocimetry
low-risk pregnancies. was also abnormal.
In another study comparing middle cere-
bral artery to umbilical artery and renal ar-
Fetal Cerebral Arteries tery studies, the middle cerebral artery stud-
In the normally developing fetus, the brain is ies were more sensitive (72% vs. 45% and
an area of low vascular impedance and re- 8%, respectively) but less specific (58% vs.
ceives continuous forward flow throughout 87% and 93%, respectively) for the predic-
the cardiac cycle. Asymmetric FGR is likely tion of adverse outcomes.36 Other investiga-
caused by redistribution of fetal blood flow tors have evaluated the cerebral to umbilical
in favor of the fetal brain, at the expense of artery Doppler ratio as a predictor of adverse
less essential organs such as subcutaneous perinatal outcomes, such as FGR, cesarean
tissue, kidneys, and liver. However, the al- delivery for FHR abnormalities, Apgar
ready low cerebral resistance has to drop score less than 7, neonatal intensive care unit
even further to enhance cerebral blood flow. admission, and neonatal complications.37
This physiologic adaptation would be ne- An abnormal ratio (ie, <1.08) had a 70% di-
glected by increased end-diastolic velocities agnostic accuracy in the prediction of FGR
and decreased S/D ratios in the cerebral ar- compared with 54% for the middle cerebral
teries of growth-restricted fetuses.33,34 For artery alone and 66% for the umbilical artery
example, one study of blood flow in the in- alone. The diagnostic accuracy of abnormal
ternal carotid and umbilical arteries of 44 cerebral/umbilical ratio for the prediction of
FGR fetuses noted that the umbilical artery adverse perinatal outcome was 90% com-
pulsatility index was increased by more than pared with 79% for the middle cerebral ar-
two standard deviations in 80% of cases, tery and 83% for the umbilical artery. The
whereas the internal carotid pulsatility index predictive values of these tests are highest
was reduced by more than two standard de- among pregnancies less than 34 weeks’ ges-
viations in only 45% of cases.34 Abnormali- tation.38
ties of umbilical artery flow correlated with In summary, in the absence of random-
fetal compromise better than intracerebral ized controlled studies, it seems that the ad-
artery blood flow impairment. This suggests dition of Doppler studies of the cerebral ar-
that high placental impedance precedes the teries to umbilical artery Doppler studies is
onset of the blood flow redistribution reflex. of little or no clinical benefit.
The middle cerebral artery pulsatility index
was assessed in a series of 576 high-risk
pregnancies undergoing umbilical artery Fetal Descending Aorta
velocimetry.35 Neither test was able to pre- Normal blood flow in the fetal descending
dict adverse perinatal outcome in normally aorta is highly pulsatile, with a minimal end-
grown fetuses. Once umbilical artery veloc- diastolic component. This part of the aorta
imetry was taken into account, cerebral ve- provides perfusion to the fetal abdominal or-
locimetry did not improve the prediction of gans, umbilical-placental circulation, and
FGR or adverse perinatal outcome, nor did lower limbs. Increased placental impedance
simultaneous assessment of both umbilical combined with redistribution of blood flow
and cerebral velocimetry in FGR fetuses from nonvital to vital organs may result in
with adverse outcome improve diagnostic changes in the aortic velocity waveforms.
accuracy. However, within the group of An elevated pulsatility index is associated
high-risk pregnancies with abnormal um- with both FGR and adverse outcomes, such
bilical artery velocimetry, the risk of being as severe growth restriction, necrotizing en-
growth-restricted and having an adverse terocolitis, fetal distress, and perinatal mor-
perinatal outcome was doubled (relative risk tality.39–47 In one group of 30 fetuses with
Doppler Evaluation of the Fetus 1021

absent end-diastolic flow in the descending Fetal Venous Circulation


aorta, abnormal waveforms were detected at Doppler studies of fetal venous blood flow
a mean of 8 days prior to the onset of fetal velocities have been reported over the last
heart rate abnormalities.43 All of the neo- decade. Physiologically, blood flow veloci-
nates were small for GA, and 66% had ab- ties in the umbilical vein and the portal cir-
normal placentas with villous fibrosis and culation are steady and nonpulsatile. How-
microfibrinous deposits. The sensitivity and ever, it has been shown that both fetal body
specificity of absent end-diastolic flow and breathing movements can interrupt the
in the descending aorta for prediction of steadiness of these blood flow patterns. In a
FGR with fetal heart rate abnormalities recent review, Huisman53 concluded that
are approximately 85% and 80%, respec- several pathologic conditions such as non-
tively.45–47 These pregnancies are also char- immune hydrops, severe FGR, and cardiac
acterized by higher rates of cesarean deliv- arrhythmias also result in an abnormal, pul-
ery, right ventricular failure, and perinatal satile, venous blood flow. However, the re-
mortality. lationship between fetal venous blood pat-
Ley et al48,49 evaluated the association terns and imminent fetal asphyxia or fetal
between abnormal fetal aortic velocity death is still unknown.
waveform, intellectual function, and minor
neurologic dysfunction at 7 years of age. UMBILICAL VEIN
They demonstrated that the verbal and glob- The presence of umbilical venous blood
al performances as well as the neurologic flow pulsatility has been associated with in-
examination were significantly better in the creased fetal morbidity and mortality.54,55
fetuses with normal aortic waveforms. Reed et al56 evaluated venous Doppler flow
These observational studies suggest that patterns in lamb fetuses and concluded that
Doppler velocimetry of the fetal aorta is, at umbilical venous velocity pulsations reflect
best, a test that predicts the onset of decom- atrial pressure changes that are transmitted
pensation due to chronic hypoxia and mal- in a retrograde fashion. Studies in human fe-
nutrition in the growth-restricted fetus. tuses demonstrated that umbilical venous
However, it is not effective for screening pulsations are sometimes detected in fetuses
and diagnosis of FGR in the general obstet- with abnormal umbilical artery velocities
ric population. and/or fetal heart rate abnormalities such as
late decelerations.55 More recently, Ferrazzi
et al57 showed that umbilical venous blood
flow is reduced in growth-restricted fetuses
Fetal Renal Artery and suggested that long-term studies be per-
Fetal renal artery velocity waveforms have formed to evaluate the clinical implications
been evaluated in normal and FGR fe- of their findings. Gudmundsson et al 58
tuses.50–52 The pulsatility index is signifi- evaluated 18 pregnancies with nonimmune
cantly elevated in those with growth restric- hydrops fetalis and found pulsating umbili-
tion, possibly indicating decreased renal cal vein velocities in 78% of these pregnan-
perfusion, which may in turn cause oligohy- cies. All the fetuses without venous pulsa-
dramnios. There is an overall negative cor- tions survived, but only 4 of the 14 with pul-
relation between the increase in pulsatility sations survived (P < 0.05).
index and the amniotic fluid volume.33 In
addition, umbilical blood sampling in FGR INFERIOR VENA CAVA
fetuses demonstrated a relationship between The flow profile within this vessel is rather
blood oxygen deficit and increased renal ar- complex: it consists of two phases of for-
tery pulsatility index. ward flow (during systole and early diastole)
1022 DIVON AND FERBER

followed by a component of reversed flow in controlled trials were able to establish only
late diastole.53 This blood flow pattern is umbilical artery Doppler velocimetry as a
significantly modulated by fetal breathing predictor of perinatal outcome in high-risk
movements (probably reflecting an in- pregnancies. Umbilical artery Doppler ve-
creased intrathoracic pressure that results in locimetry is an acceptable tool in the diag-
a temporary collapse of the inferior vena nosis of growth-restricted fetuses, in the dif-
cava). The flow velocity waveform of the fe- ferentiation of these fetuses from constitu-
tal inferior vena cava was used to diagnose tionally small but otherwise healthy fetuses,
arrhythmias by comparing it with the wave- and in the reduction of perinatal mortality in
form of the aorta. Because of the proximity high-risk pregnancies. In addition, this test-
of these vessels it is easy to record their ing modality might have a role in the predic-
waveforms simultaneously. Doppler veloc- tion of long-term neurologic outcome.
ity waveforms of the fetal inferior vena cava Large-scale randomized controlled trials are
represent the right atrial activity, whereas needed to establish the clinical utility of
those of the aorta reflect ventricular contrac- Doppler velocimetry studies of other mater-
tion.59 nal, placental, and fetal vessels.

DUCTUS VENOSUS
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Doppler Evaluation of the Fetus 1023

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