[Doppler velocimetry in patients with preeclampsia]

[Article in Bulgarian]

Ivanov S, Mikhova M, Sigridov I, Batashki I.

Abstract

Doppler velocimetry is a fast and convenient method for monitoring of fetal well being in high risk pregnancies.

Doppler velocimetry is more specific and sensitive method of fetal surveillance than cardiotocography. The study's

objective is to prove Doppler's effectiveness in predicting perinatal outcome in preeclamptic pregnancies. A

retrospective study is designed, including pregnant women, diagnosed with preeclampsia, admitted to Maternity

hospital "Majchin dom" for ten years. Doppler study was made and results were correlated to Apgar score, umbilical

artery pH and base excess of the neonate at delivery. A correlation between RI of umbilical artery, uterine arteries

and Apgar score at 5th minute was demonstrated. In severe cases correlation between RI of umbilical artery and

neonatal pH was found. CONCLUSION: Doppler velocimetry is an effective method of fetal surveillance in

pregnancies, complicated by preeclampsia

Increased uterine artery vascular impedance is related to adverse outcome of

pregnancy but is present in only one-third of late third-trimester pre-eclamptic
women.

Li H, Gudnason H, Olofsson P, Dubiel M, Gudmundsson S.

University of Lund, Department of Obstetrics and Gynecology, Malmö University Hospital, Malmö, Sweden.

Abstract

OBJECTIVE: Signs of increased uterine artery vascular impedance in mid-gestation are strongly related to pre-

eclampsia later in pregnancy. Whether this is true for the late third trimester is, however, unclear. The aim of the

present study was to analyze the frequency of increased uterine artery vascular impedance in the third trimester, and

its relationship to abnormal umbilical artery Doppler and adverse outcome of pregnancy.

METHODS: This was a retrospective study of uterine and umbilical artery Doppler velocimetry in 570 pregnancies

complicated by pre-eclampsia. The managing clinician was informed only about the umbilical artery flow. The Doppler
recordings were related to severity of pre-eclampsia, prematurity, fetal growth restriction, and rates of Cesarean

section and admission to neonatal intensive care.

RESULTS: Increased umbilical artery vascular impedance was seen in 59 cases (10.4%), seven having absent or

reversed end-diastolic flow. Uterine artery notching was seen in 145 cases (25%), 88 (15%) having bilateral notches.

Either increased uterine artery pulsatility index (PI) or notching, or both, were seen in 207 women (36.3%). In 108

women with severe pre-eclampsia, 38 (35.2%) had uterine artery notching. Signs of increased uteroplacental

vascular impedance were more common in severe than in mild pre-eclampsia (57.4% vs. 31.4%), in premature than

in term pregnancies (70.9% vs. 28.4%), and were more prevalent than abnormality in the umbilical artery (36.3% vs.

10.4%).

CONCLUSION: Only one-third of pre-eclamptic cases showed signs of increased uterine artery vascular impedance

in the third trimester. However, signs of increased vascular impedance were much more frequent in the uterine than

in the umbilical arteries and were strongly related to adverse outcome of pregnancy.

[Umbilical artery Doppler velocimetry and adverse perinatal outcome in severe

pre-eclampsia]

[Article in Spanish]

Arauz JF, León JC, Velásquez PR, Jiménez GA, Pérez CJ.

Departamento de complicaciones hipertensivas del embarazo, Hospital de Ginecología y Obstetricia Luis Castelazo

Ayala, Instituto Mexicano del Seguro Social, México, DF. jfromarauz@hotmail.com

Abstract

BACKGROUND: Abnormal placentation is a main preeclampsia characteristic. Its cause is a maternal spiral veins

trophoblastic invasion failure, which conditions vascular resistances raise and uterus-placental perfusion decrease.

OBJECTIVE: To determine the relationship between umbilical artery Doppler waveform and adverse perinatal

outcome in patients with severe preeclampsia.

PATIENTS AND METHOD: A prospective, observational and transversal study was done to analyze patients

between 27 to 33 weeks of gestation with expectant management of severe preeclampsia from January 2004 to

January 2006. Umbilical artery velocimetry studies were performed at least once a week by means of pulsed Doppler
equipment with a 3.5 MHz transducer. Only the results of the last Doppler examination performed within 7 days of

delivery were considered in the correlation with perinatal outcomes. The indications for delivery were maternal or fetal

(non reassuring nonstress test or biophysical profile < or = 4). An abnormal Doppler velocimetry was defined as

pulsatility index being higher than percentile 95 for gestational age, or absent or reversed end diastolic velocity

waveforms in umbilical artery. The statistical analysis was done with chi2 test and Student t test.

RESULTS: There were included 43 patients in this study. Twenty-two (52%) had an abnormal Doppler umbilical

artery pulsatility index and 21 (49%) obtained a normal umbilical artery waveform. In the first group 13 (59%) had a

positive end diastolic velocities with elevated pulsatility index values, end diastolic velocities were absent in seven

cases (32%) and reversed in two cases (9%). Neonates with abnormal pulsatility index had a lower birth weight

(1,174 vs 1,728 g), lower Apgar score at 5 minutes, higher admission to the neonatal intensive care unit (86.4 vs

43%), and significant neonatal morbidity compared with those with normal velocimetry (p < 0.05). There were no

perinatal deaths with normal umbilical Doppler waveform. There were six perinatal deaths in the abnormal Doppler

velocimetry. Two cases occurred with positive end diastolic velocity (15%), two cases with absent end diastolic

velocity (28%) and two deaths with reversed flow of the umbilical artery (100%).

CONCLUSION: An abnormal Doppler umbilical artery waveform is associated with poor perinatal outcome and is a

strong predictor of perinatal mortality.

CONCLUSIONS: Umbilical artery blood flow parameters as indicators for determining the fetal status can be used to

predict the pregnancy outcomes.

Umbilical and middle cerebral artery Doppler indices in patients with

preeclampsia.

Ozeren M, Dinç H, Ekmen U, Senekayli C, Aydemir V.

Karadeniz Technical University, Faculty of Medicine, Department of Obstetrics and Gynecology, Trabzon, Turkey.

Abstract

OBJECTIVE: To compare changes in Doppler ultrasound studies of fetal circulation in normal pregnancies with those

of a group of preeclamptic patients both with and without intrauterine growth retardation and to demonstrate the best

index for predicting adverse perinatal outcome or IUGR.

STUDY DESIGN: A cross-sectional study was performed on 125 normal pregnancies and 62 preeclamptic patients at

31-40 weeks of gestation. The umbilical artery systolic-diastolic ratio (UA S/D), UA pulsatility index (PI), the middle

cerebral artery (MCA) PI, and the ratio of MCA PI to UA PI were measured. The mean values of the Doppler indices

were compared. Different cut-off values (mean +/-2 S.D.) were used for the 31st-35th and the 36th-40th weeks.

RESULTS: Significant differences were found between normal pregnancies and preeclamptic patients without IUGR

using the mean MCA PI and the MCA PI/UA PI ratio. In the preeclamptic patients with IUGR, all the mean Doppler

indices were different from those of the normal pregnancies. In the preeclamptic patients with IUGR the values were

different from the preeclamptic patients without IUGR, except for the MCA PI at 31-35 weeks. The UA S/D had the

highest sensitivity (88%) and diagnostic accuracy (94%) in predicting the adverse perinatal outcome. The MCA PI/UA

PI ratio showed the highest predictive value in determining IUGR by a sensitivity of 84% and a diagnostic accuracy of

87%.

CONCLUSION: Both abnormal umbilical Doppler indices and cerebral-umbilical ratio are strong predictors of IUGR

and of adverse perinatal outcome in preeclampsia. The MCA PI alone is not a reliable indicator. The combination of

umbilical and fetal cerebral Doppler indices may increase the utility of Doppler ultrasound in preeclamptic subjects.

Umbilical and middle cerebral artery Doppler indices in patients with preeclampsia

Mehmet Özerena , Hasan Dinçb, Ümit Ekmena, Cem Senekaylib, Vedat Aydemira

Received 10 February 1998; received in revised form 22 June 1998; accepted 31 July 1998.

Abstract

Objective: To compare changes in Doppler ultrasound studies of fetal circulation in normal pregnancies with
those of a group of preeclamptic patients both with and without intrauterine growth retardation and to
demonstrate the best index for predicting adverse perinatal outcome or IUGR. Study design: A cross-sectional
study was performed on 125 normal pregnancies and 62 preeclamptic patients at 31–40 weeks of gestation.
The umbilical artery systolic–diastolic ratio (UA S/D), UA pulsatility index (PI), the middle cerebral artery (MCA)
PI, and the ratio of MCA PI to UA PI were measured. The mean values of the Doppler indices were compared.
Different cut-off values (mean±2 S.D.) were used for the 31st–35th and the 36th–40th weeks. Results:
Significant differences were found between normal pregnancies and preeclamptic patients without IUGR using
the mean MCA PI and the MCA PI/UA PI ratio. In the preeclamptic patients with IUGR, all the mean Doppler
indices were different from those of the normal pregnancies. In the preeclamptic patients with IUGR the values
were different from the preeclamptic patients without IUGR, except for the MCA PI at 31–35 weeks. The UA
S/D had the highest sensitivity (88%) and diagnostic accuracy (94%) in predicting the adverse perinatal
outcome. The MCA PI/UA PI ratio showed the highest predictive value in determining IUGR by a sensitivity of
84% and a diagnostic accuracy of 87%. Conclusion: Both abnormal umbilical Doppler indices and cerebral–
umbilical ratio are strong predictors of IUGR and of adverse perinatal outcome in preeclampsia. The MCA PI
alone is not a reliable indicator. The combination of umbilical and fetal cerebral Doppler indices may increase
the utility of Doppler ultrasound in preeclamptic subjects.

Color doppler evaluation of cerebral-umbilical pulsatility ratio

and its usefulness in the diagnosis of intrauterine growth
retardation and prediction of adverse perinatal outcome
Shahina Bano, Vikas Chaudhary,1 Sanjay Pande,2 VL Mehta,2 and AK Sharma2
Department of Radiodiagnosis, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi - 110 001, India
1
Lady Hardinge Medical College and associated Hospitals, New Delhi - 110 001, India
2
N.S.C.B. Medical College and Hospital, Jabalpur, Madhya Pradesh - 482 003, India
Correspondence: Dr. Shahina Bano, Room No. 204, Doctor's Hostel, Dr. Ram Manohar Lohia Hospital and
PGIMER, New Delhi - 110 001, India. E-mail: dr_shahinaindia@yahoo.com
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

• Other Sections▼
o Abstract
o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

Abstract
Objective:
The aim of our study was to evaluate the usefulness of the pulsatility index (PI) of the umbilical
artery (UA) and that of the fetal middle cerebral artery (MCA), as well as the ratio of the MCA
PI to the UA PI (C/U ratio), in the diagnosis of small-for-gestational-age (SGA) fetuses and in
the prediction of adverse perinatal outcome.
Materials and Methods:
The study population comprised 90 pregnancies of 30-41 weeks gestation that had been
diagnosed clinically as intrauterine growth retardation (IUGR) over a period of 1 year. The UA
PI and the MCA PI as well as the C/U ratio were calculated.
Results:
Of the 90 pregnancies in the study, 24 showed abnormal UA PI. Among these, 21 (87.5%) were
SGA and 19 (79.2%) had adverse perinatal outcome. Of the four of the 90 pregnancies that
showed abnormal MCA PI, all were SGA and had adverse perinatal outcome. Similarly, of the
20 out of 90 pregnancies that showed abnormal C/U ratio (<1.08), all 20 (100%) were SGA and
had adverse perinatal outcome. The results were correlated with parameters of fetal outcome.
Conclusion:
Inferences drawn from the study were: (1) The C/U ratio is a better predictor of SGA fetuses and
adverse perinatal outcome than the MCA PI or the UA PI used alone, (2) The UA PI can be used
to identify IUGR per se and (3) The MCA PI alone is not a reliable indicator for predicting fetal
distress.
Keywords: Intrauterine growth retardation, pulsatility index, umbilical artery pulsatility index,
middle cerebral artery pulsatility index, middle cerebral artery to umbilical artery pulsatility
index ratio

• Other Sections▼
o Abstract
o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

Introduction
Placental insufficiency, whether primary or secondary to maternal factors such as hypertension,
poor nutrition, etc., is the most common cause of intrauterine growth retardation (IUGR), which
is an important obstetric problem on account of the high associated perinatal mortality and
morbidity. It is essential to recognize placental insufficiency early so that its hazards can be
reduced, if not prevented.
Doppler USG enables a better understanding of the hemodynamic changes and has therefore
become one of the most important clinical tools for fetomaternal surveillance in high-risk
pregnancies. It can be credited with causing a significant decrease in perinatal mortality and
morbidity.[1] The purpose of our study was to evaluate the usefulness of the pulsatility index
(PI) of the umbilical artery (UA) and that of the middle cerebral artery (MCA), as well as the
ratio of the MCA PI to the UA PI (C/U ratio), in the diagnosis of small-for-gestational-age
(SGA) fetuses and the prediction of adverse perinatal outcome.

• Other Sections▼
 o Abstract
o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

Materials and Methods

The study population comprised 90 pregnancies of 30-41 weeks’ gestation that had been
diagnosed clinically as IUGR and referred for USG over a period of 1 year.
Of the 90 cases, 45 showed normal fetal growth parameters, forming the control group; 45
fetuses had abdominal circumferences that were less than the 10th percentile for their respective
gestational ages along with elevated head circumference (HC)/abdominal circumference (AC)
ratios, and these patients formed the study group. All the 90 patients were subjected to a repeat
USG examination after 15 days, when the findings of the initial study were reconfirmed. All 90
patients were subjected to duplex Doppler examination, using a 3.5-MHz transducer with 3-mm
sample volume and medium filter. During the examination, the patient was in a semirecumbent
position and the fetus was in a quiet, resting state. The flow velocity waveforms were recorded
from the UA and the fetal MCA. After technically satisfactory Doppler waveforms had been
recorded, the PI of the UA and of the MCA was noted over three consecutive cardiac cycles and
the ratio of the MCA PI to the UA PI (the C/U ratio) was calculated. A single reading was
recorded in the control group and two readings were recorded in the study group. The
pregnancies were followed-up and the final perinatal outcome of each case was noted. Various
intrapartum and neonatal indicators were used to assess the outcome, with an adverse outcome
being defined as the presence of one or more of these indicators. Gramellini et al.[2] have quoted
the normal values of UA PI and MCA PI and the C/U ratio, and we used those values for
interpreting the Doppler indices. The mean values quoted by Gramellini et al. ±2 SD were
considered as normal for the corresponding gestational age. According to Gramellini et al.,[2]
the C/U ratio remains constant in the last 10 weeks of pregnancy and therefore we used a single
cut-off value of 1.08 throughout this study where all cases were of 30-41 weeks' gestation.
Doppler velocimetry was considered as normal when the C/U ratio was above 1.08, and below
that value, velocimetry was considered abnormal. The PI in the IUGR group was compared with
that in the normal study group using the chi square test and Fischer's exact test. P < 0.05 was
considered significant.

• Other Sections▼
o Abstract
o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

Results
The results are presented in the form of tables [Tables 1–5] Of the 90 pregnancies in the
study, 24 showed abnormal UA PI. Among these, 21 (87.5%) were SGA and 19 (79.2%) had
adverse perinatal outcome. Four of the 90 pregnancies showed abnormal MCA PI and all four
(100%) fetuses were SGA and all (100%) had adverse perinatal outcome. Perinatal death was
noted in one pregnancy, which showed a normal MCA PI but an abnormal UA PI and C/U ratio.
Twenty of the 90 pregnancies showed an abnormal C/U ratio (<1.08). Of these, 20 (100%)
fetuses were SGA and all had an adverse perinatal outcome. Tables 4 and 5 depict the diagnostic
performance of various Doppler flow indices in identifying SGA fetuses and predicting adverse
perinatal outcome. The sensitivity and negative predictive values (NPVs) were higher for the
C/U ratio and UA PI, whereas significantly lower for MCA PI. The specificity and positive
predictive value (PPV) of the C/U ratio and MCA PI were equal to each other but higher than
that of UA PI.

Table 1
Perinatal outcome of the study population according to the values of umbilical artery
pulsatility index

Table 1
Perinatal outcome of the study population according to the values of
umbilical artery pulsatility index
Normal PI (n Abnormal PI (n
Serial number P value
= 66) (%) = 24) (%)
Adverse perinatal outcome 5 (7.6) 19 (79.2) <0.0001
Caesarian section for fetal distress 2 (3.0) 16 (66.7) <0.0001
 Normal PI (n Abnormal PI (n
Serial number P value
= 66) (%) = 24) (%)
Apgar score <7 at 5 min 1 (1.5) 10 (14.7) <0.0001
Stay in NICU >8 days 4 (6.1) 13 (44.2) <0.0001
Still birth/perinatal death - 2 (8.3) <0.01
Small-for-gestational age (birth
weight less than 10th percentile for 24 (36.4) 21 (87.5) <0.0001
gestational age)
NICU - Neonatal intensive care unit; CS - Caesarian section

Table 5
Diagnostic performance of pulsatility index and C/U ratio for adverse perinatal outcome

Table 5
Diagnostic performance of pulsatility index and C/U ratio for adverse
perinatal outcome
n = 90 No. of findings
Sensitivity Specificity DA
PPV NPV
(%) (%) (%)
TP FN FP TN
UA 19 5 5 61 79.2 92.4 79.2 92.4 88.9
MCA 4 20 0 66 16.7 100 100 76.7 77.8
C/U
20 4 0 66 83.3 100 100 94.3 95.6
ratio
TP - True positive; FN - False negative; FP - False positive; TN - True negative

Table 4
Diagnostic performance of pulsatility index and C/U ratio for small-for-gestational-age
infants

Table 4
Diagnostic performance of pulsatility index and C/U ratio for small-for-
gestational-age infants
n = 90 No. of findings
Sensitivity Specificity PPV NPV DA
(%) (%) (%) (%) (%)
TP FN FP TN
UA 21 24 3 42 46.7 93.3 87.5 63.6 70
MCA 4 41 0 45 8.9 100 100 52.3 54.4
C/U
20 25 0 45 44.4 100 100 64.3 72.2
ratio
n - No. of study population; PPV - Positive predictive value; NPV - Negative predictive value; DA -
Diagnostic accuracy; TP - True positive; FN - False negative; FP - False positive; TN - True negative

Table 2
Perinatal outcome of the study population according to the values of middle cerebral artery
pulsatility index

Table 2
Perinatal outcome of the study population according to the values of middle
cerebral artery pulsatility index
Normal PI (n Abnormal PI
Serial number P value
= 86) (%) (n = 4) (%)
Adverse perinatal outcome 20 (23.3) 4 (100) <0.001
Caesarian section for fetal distress 15 (17.4) 3 (75.0) <0.05
Apgar score <7 at 5 min 8 (9.3) 3 (75.0) <0.01
Stay in NICU >8 days 14 (16.3) 3 (75.0) <0.05
Still birth/perinatal death 1 (1.2) 1 (25.0) <0.001
Small-for-gestational age (birth
weight less than 10th percentile for 41 (47.7) 4 (100) <0.05
gestational age)

Table 3

Perinatal outcome of the study population according to the cerebral-umbilical ratio

Table 3
Perinatal outcome of the study population according to the cerebral-
umbilical ratio
 Normal PI Abnormal PI
Serial number ratio (>1.08) (n ratio (<1.08) (n = P value
= 70) (%) 20) (%)
Adverse perinatal outcome 4 (5.7) 20 (100) <0.0001
Caesarian section for fetal
1 (1.4) 17 (85.0) <0.0001
distress
Apgar score <7 at 5 min 2 (2.9) 9 (45.0) <0.0001
Stay in NICU >8 days 4 (5.7) 13 (75.0) <0.0001
Still birth/perinatal death - 2 (10.0) <0.01
Small-for-gestational age (birth
weight less than 10th percentile 25 (35.71) 20 (100) <0.0001
for gestational age)

• Other Sections▼
o Abstract
o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

Discussion
IUGR is a pathological condition strongly related to the development and function of the
uteroplacental and fetoplacental circulations. An adequate fetal circulation is necessary for
normal fetal growth. To facilitate this, remarkable changes occur in the maternal, placental and
fetal vasculatures.
UA velocimetry correlates with hemodynamic changes in the fetoplacental circulation. With an
increase in the number of tertiary stem villi and arterial channels, as the fetoplacental
compartment develops, the impedance in the UA decreases. A diastolic component in the UA
flow velocity waveform (FVW) appears during the early second trimester, i.e., at 15 weeks'
gestation, and progressively increases with an increase in the gestational age. A mature UA FVW
is usually achieved by 28- 30 weeks.[3] The normal UA waveform pattern shows low impedance
and high diastolic flow with a low PI [Figure 1]. During normal pregnancy, the MCA shows high
resistance and low diastolic flow with an increase in the PI index [Figure 2].
 Figure 1
Color Doppler of the umbilical artery shows a normal UA waveform pattern with low
impedance, high diastolic flow and decreased pulsatility index

Figure 1
Color Doppler of the umbilical artery shows a normal UA waveform pattern with low impedance, high
diastolic flow and decreased pulsatility index

Figure 2
Color Doppler of the normal middle cerebral artery shows a normal MCA waveform
pattern, with high resistance, low diastolic flow and increased pulsatility index

Figure 2
Color Doppler of the normal middle cerebral artery shows a normal MCA waveform pattern, with high
resistance, low diastolic flow and increased pulsatility index

Gramellini et al.[2] calculated the C/U ratio and found that it remained constant in the last 10
weeks of pregnancy. We, therefore, used a single cut-off value of 1.08 for all cases of 30–41
weeks of gestation. Above this value, Doppler velocimetry was considered normal and, below it,
abnormal. Using this cut-off value, we could divide the study population into two groups: Those
with a normal ratio and those with an abnormal ratio.
In IUGR, umbilical blood flow is significantly reduced, mainly due to changes in the placental
vascular resistance. Giles et al.[4] have found that a decrease in the number of resistance vessels
in the tertiary stem villi in the placenta causes an increase in resistance, leading to decreased
flow through the UA and an increase in the UA PI. This is described as umbilical placental
insufficiency. Fleischer and Schulman[1] have found that in IUGR complicated by pregnancy-
induced hypertension, there is inadequate trophoblastic invasion of the spiral arteries, leading to
increased resistance in the spiral arteries and decreased blood flow in the placental vascular bed
and in the UA, thereby resulting in an increase in the UA PI. This is described as uteroplacental
insufficiency. Several blood flow classes (0-IIIb) have been defined by Hofer et al.[5] to describe
abnormal UA waveform patterns. Increasing pathological significance is ascribed to a decrease
in diastolic flow (class II), absence of diastolic flow (class IIIa) and reversal of diastolic flow
(class IIIb). All these patterns were associated with increased UA PI [Figure [Figure3a3a–c].
Patients with absent end-diastolic volume (AEDV) and reverse end-diastolic volume (REDV)
have the gravest outcome. Fetuses with AEDV require intensive surveillance as fetal well-being
may deteriorate within a few days. Fetuses with REDV are most severely compromised. REDV
is indicative of a preterminal fetal state.

Figure 3 (a-c)
Abnormal umbilical artery waveform patterns showing markedly reduced diastolic flow
and increased pulsatility index (a) absent diastolic flow (b) and reverse diastolic flow (c)
Figure 3 (a-c)
Abnormal umbilical artery waveform patterns showing markedly reduced diastolic flow and increased
pulsatility index (a) absent diastolic flow (b) and reverse diastolic flow (c)

In pregnancies with chronic fetal hypoxia, the blood volume in the fetal circulation is
redistributed in favor of vitally important organs, i.e., the heart, kidneys and brain.
Vasodilatation of the MCA, with an increase in diastolic flow through it, results in a decrease in
its PI. The resulting hyperperfusion is considered pathological [Figure 4]. This ‘brain-sparing
effect’ is associated with an abnormal C/U ratio (<1.08). However, if hypoxia persists, the
diastolic flow returns to the normal level. Presumably, this reflects a terminal decompensation in
the setting of acidemia or brain edema.[5]

Figure 4
Abnormal middle cerebral artery waveform pattern shows low resistance and high diastolic
flow due to cerebral vasodilatation (the brain-sparing effect)

Figure 4
Abnormal middle cerebral artery waveform pattern shows low resistance and high diastolic flow due to
cerebral vasodilatation (the brain-sparing effect)
Thus, in asymmetrical growth retardation, there is a high UA PI and low MCA PI. As a result,
the C/U ratio is lower than normal in growth-retarded fetuses. A significant association between
the C/U ratio and the HC/AC ratio can be seen. The C/U ratio remains constant during the last 10
weeks of gestation and provides better diagnostic accuracy than either vessels' PI considered
alone.[2]
In our study, we found that the C/U ratio was a better predictor of SGA newborns and adverse
perinatal outcome than either the MCA PI or UA PI alone. The C/U ratio demonstrated a 100%
specificity and PPV in diagnosing IUGR and predicting adverse perinatal outcome, but had a low
sensitivity of 44.4% and an NPV of 64.3% in diagnosing IUGR, but a relatively higher
sensitivity of 83.3% and an NPV of 94.3% for predicting adverse perinatal outcome. The
sensitivity and NPV of the C/U ratio were comparable to those of UA PI, but much higher than
those of MCA PI.
Although the specificity and PPV of MCA PI was 100% in our study, the sensitivity and NPV
were much lower. Therefore, a normal MCA PI may not be an indicator of fetal well-being. We
also observed perinatal death in one pregnancy, which had shown a change in the MCA PI from
abnormal to normal. This suggests that normalization of the MCA PI during chronic hypoxia
may not be an indicator of fetal well-being as, in severe fetal hypoxia, the brain-sparing effect
breaks down due to acidemia or brain edema and the low MCA PI becomes normal. Therefore,
MCA PI alone is not a reliable indicator and, in such a situation, the increase in the UA PI can
predict a severely growth-restricted infant. Detection of this change from abnormal to normal
MCA PI with prolonged hypoxia is associated with severe growth retardation and predicts
perinatal death.
We also found that for the diagnosis of IUGR, the sensitivity of UA PI was 46.7% as compared
with 8.9% for MCA PI and 44.4% for the C/U ratio. This relatively higher sensitivity of the UA
PI is probably because it directly reflects the resistance in the placental vascular bed. Thus, in
cases of suspected IUGR, the measurement of PI value in the UA may be enough to detect
IUGR.
Our results were more encouraging for the prediction of adverse perinatal outcome rather than
diagnosing IUGR. It has been estimated that 41-86% of SGA babies can be detected with the
routine use of symphysis-fundal height measurements.[6] According to one meta-analysis of
USG fetal biometry, AC and estimated fetal weight (EFW) are the best predictors of fetal weight
below the 10th percentile.[7] In high-risk populations, the sensitivity of using AC below the 10th
percentile is 73-95%, whereas with EFW, the sensitivity is 43-89%. In low-risk populations, the
corresponding sensitivities are 48-64% for AC and 31-73% for EFW.[8] Biophysical profile is
another method for detecting IUGR, with a sensitivity of 77.7%.[9]
We further found that when compared with other modalities, although Doppler velocimetry was
relatively less sensitive for diagnosing SGA fetuses, because uteroplacental insufficiency is just
one cause of IUGR, it proved to be very useful in predicting IUGR fetuses at risk for adverse
perinatal morbidity and mortality. None of the other modalities has been as promising in
detecting adverse perinatal outcome as Doppler velocimetry. Among the number of biophysical
tests available to assess fetal well-being, the most common methods are amniotic fluid volume
(AFV), biophysical profile scoring (BPS) and nonstress test (NST). A reduced AFV (either
measured by maximum vertical pocket < 2 cm or a four-quadrant amniotic fluid index (AFI) < 5
cm poorly correlates with the actual AFV and does not accurately predict adverse perinatal
outcome. A review of 18 studies indicated that an AFI < 5 cm was associated with an increased
risk of Cesarean section for fetal distress (relative risk [RR] 2.2; 95% confidence interval [CI]
1.5-3.4) and Apgar score of < 7 at 5 min (RR 5.2; 95% CI 2.4-11.3), but not with neonatal
acidosis.[10] Large observational studies have shown an association between reduced AFV and
perinatal morbidity and mortality, but the predictive value is poor (< 10%) and, also, there is
little evidence to support intervention with isolated oligohydramnios (with a normal UA
Doppler).[11] Yoon et al.[12] attempted to compare the performance of BPS and UA Doppler
velocimetry in the identification of fetal acidemia, hypoxemia and hypercarbia as determined by
PH and gas analysis of fetal blood obtained by cordocentesis in 24 patients. Although they found
a strong relationship between the degree of fetal acedemia and hypercarbia and the results of UA
Doppler velocimetry and BPS, Doppler velocimetry proved to be a better explanatory variable
for these outcomes than the BPS.[12] Another study was performed by Gonzalez et al.[13] to
compare the efficacy of NST, BPS and abnormal Doppler findings in predicting adverse
perinatal outcomes in IUGR. The PPVs of abnormal Doppler for respiratory distress syndrome
and the composite of adverse outcomes were 36% and 42%, respectively. Of the testing
modalities compared, only abnormal Doppler significantly predicted respiratory distress
syndrome and the composite of adverse outcome. Hence, they concluded that in cases of IUGR,
the presence of abnormal Doppler was the best predictor of adverse perinatal outcome.[13]
Padmagirison Radhika et al.[14] conducted prospective antenatal fetal surveillance in 55 women
to compare the efficacy of Doppler velocimetry and NST in predicting fetal compromise in utero
in cases of severe pre-eclampsia or IUGR. There were 29 cases with abnormal Doppler and 20
cases with abnormal NST. In addition, Doppler abnormalities preceded NST changes with a lead
time of 4.14 days and there were 10 perinatal deaths, six of which occurred in the group where
both the tests were abnormal. They concluded that Doppler identifies fetal compromise earlier
than NST. The lead time helps to plan delivery in preterm compromised pregnancies, resulting in
better perinatal survival.[14]

• Other Sections▼
o Abstract
o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

Conclusion
Thus, we conclude that for the diagnosis of IUGR alone, Doppler velocimetry is not sensitive
enough and a normal study does not rule out IUGR, which should then be diagnosed using other
means. If the study, however, is abnormal, the specificity and PPV are virtually 100%. The
sensitivity and specificity of the C/U ratio to assess adverse perinatal outcome however are high.
Among the Doppler indices, the C/U ratio is a better predictor of SGA fetuses and adverse
perinatal outcome than either the UAPI or the MCA PI alone, with a high specificity and PPV.
However, measurement of the UAPI (among all the Doppler indices) is enough to detect IUGR
per se, probably because UAPI is a direct reflection of the resistance in the placental vascular
bed. The MCA PI alone is not a reliable indicator, and its efficiency in predicting fetal distress is
found to be lower than that of UAPI.

Footnotes
Source of Support: Nil
Conflict of Interest: None declared.

• Other Sections▼
o Abstract
 o Introduction
o Materials and Methods
o Results
o Discussion
o Conclusion
o References

References
1. Fleischer A, Schulman H, Farmakides G, Bracero L, Blattner P, Randolph G. Umbilical artery flow velocity waveforms
and intrauterine growth retardation. Am J Obstet Gynecol. 1985;151:502–5. [PubMed]
2. Gramellini D, Folli MC, Raboni S, Vadora E, Merialdi A, et al. Cerebral umbilical Doppler ratio as a predictor of
adverse perinatal outcome. Cerebral and umbilical ratio: Obstet Gynecol. 1992;79:416–20.
3. Schulman H, Fleischer A, Stern W, Farmakides G, Jagani N, Blattner P, et al. umbilical wave ratios in human
pregnancy. Am J Obstet Gynecol. 1984;148:985–90. [PubMed]
4. Giles WB, Trudinger BJ, Baird PJ. Fetal umbilical flow velocity waveform and placental resistance pathological
correlation. Br J Obstet Gynaecol. 1985;92:31–8. [PubMed]
5. Tatjana Reihs, Matthias Hofer. In: Obstetrics and gynecology Sonography. 2nd ed. Matthias Hofer., editor. New York:
Thieme; 2004. pp. 61–72.
6. Quaranta P, Currell R, Redman CW, Robinson JS. Prediction of small-for-dates infants by measurement of symphysis-
fundal height. Br J Obstet Gynaecol. 1981;88:115–9. [PubMed]
7. Chang TC, Robson SC, Boys RJ, Spencer JA. Prediction of the small for gestational age infant: Which ultrasonic
measurement is best? Obstet Gynecol. 1992;80:1030–8. [PubMed]
8. Warsof SL, Cooper DJ, Little D, Campbell S. Routine ultrasound screening for antenatal detection of intrauterine
growth retardation. Obstet Gynecol. 1986;67:33–9. [PubMed]
9. Afzal A, Nasreen K. Biophysical score in high risk pregnancy. Prof Med J. 2006;13:362–9.
10. Chauhan SP, Sanderson M, Hendrix NW, Magann EF, Devoe LD. Perinatal outcome and amniotic fluid index in the
antepartum and intrapartum periods: A meta-analysis. Am J Obstet Gynecol. 1999;181:1473–8. [PubMed]
11. Forfar J, Mclntosh N, Arneil GC, et al. Forfar and Arneil text book of pediatrics. Google book result. 2003:167–8.
12. Yoon BH, Romero R, Roh CR, Kim SH, Ager JW, Syn HC, et al. Relationship between the fetal biophysical profile
score, umbilical artery Doppler velocimetry, and fetal blood acid-base status determined by cordocentesis. Am J Obstet
Gynecol. 1993;169:1586–94. [PubMed]
13. Gonzalez JM, Stamilio DM, Ural S, Macones GA, Odibo AO. Relationship between abnormal fetal testing and adverse
perinatal outcomes in intrauterine growth restriction. Am J Obstet Gynecol. 2007;196:48–51. [PubMed]
14. Padmagirison R, Rai L. Fetal doppler versus NST as predictors of adverse perinatal outcome in severe preeclampsia
and fetal growth restriction. J Obstet Gynecol. 2006;56:134–8.
 FETAL OXYGENATION

Oxygenation is the process of transporting molecular oxygen from air to the tissues of the
body. In the fetus, this involves, first, oxygen transfer across the placenta, second,
reversible binding of oxygen to fetal hemoglobin and fetal blood flow, and, third, oxygen
consumption for growth and metabolism. Energy is derived from the combination of
oxygen and glucose to form carbon dioxide and water. Removal of carbon dioxide and
protection against acidosis is by the reverse of the mechanisms for oxygen delivery and is
helped by the rapid diffusion, high solubility and volatility of this gas. In the adult, carbon
dioxide is excreted in the lungs while bicarbonate and hydrogen ions are removed by the
kidney. In the fetus, both these functions are carried out by the placenta.

When there is inadequate oxygen supply, the Krebs cycle cannot operate and pyruvate is
converted to lactic acid. This enters the blood, leading to systemic acidosis unless it is
either metabolized or excreted. The amount of oxygen bound to hemoglobin is not linearly
related to oxygen tension (pO2). Each type of hemoglobin has a characteristic oxygen
dissociation curve which can be modified by environmental factors, such as pH and the
concentration of 2,3-diphosphoglycerate (2,3-DPG). For example, when 2,3-DPG rises, in
response to anemia or hypoxia, it binds to and stabilizes the deoxygenated form of
hemoglobin, resulting in a shift of the oxygen dissociation curve to the right and therefore
release ofoxygen to the tissues.

Although, in vitro , both adult (HbA) and fetal (HbF) hemoglobins have the same oxygen
dissociation curves, human adult blood has a lower affinity for oxygen than fetal because
of its greater binding of 2,3-DPG. The higher affinity of fetal blood helps placental transfer
of oxygen. Furthermore, since the P50 of fetal blood is similar to the umbilical arterial pO2,
the fetus operates over the steepest part of the hemoglobin oxygen dissociation curve
and, therefore, a relatively large amount of oxygen is released from the hemoglobin for a
given drop in pO2.

Normal fetal oxygenation

In normal fetuses, the blood oxygen tension is much lower than the maternal, and it has
been suggested that this is due either to incomplete venous equilibration of uterine and
umbilical circulations and/or to high placental oxygen consumption 1,2. Studies in a variety
of animals have also demonstrated that the umbilical venous blood pO2 is less than half
the maternal arterial pO2 and this observation led to the concept of ‘Mount Everest in
utero'. However, the high affinity of fetal hemoglobin for oxygen, together with the high
fetal cardiac output in relation to oxygen demand, compensates for the low fetal pO2 (3).
The umbilical venous and arterial pO2 and pH decrease, while pCO2 increases, with
gestation1,2. The blood oxygen content increases with gestational age because of the rise
in fetal hemoglobin concentration 2. Fetal blood lactate concentration does not change
with gestation and the values are similar to those in samples obtained at elective Cesarean
section at term 2. The umbilical venous concentration is higher than the umbilical arterial,
 Doppler in Obstetrics
Copyright © 2002 by Kypros Nicolaides, Giuseppe Rizzo, Kurt Hecker and Renato
Ximenes