Thesis Finnal Form (2019 To 2023)

A thesis Submitted by
NAHIDA SHAHID (BSMIT-F19-347), NAGINA ASLAM(BSMIT-F19-357),

M. NAEEM SAJID(BSMIT-F19-416)
Superior University
CORRELATION OF DOPPLER INDICES OF

UA AND MCA IN NORMAL AND ANEMIC
PREGNANT PATIENT
Name of The Student
In the Partial Fulfillment for the Award of

Bachelor of Science in Medical Imaging Technology
SUPERVISOR: DR TAYYABA ASLAM
(MID)
Co-SUPERVISOR: DR ABDUAL REHMAN AMIR
(Program)FAHS (2019-2023)
(MBBS, DMRD)
Senior Radiologist, Radiology Department
Department of Allied Health Sciences

The Superior College Lahore
(2019-2023)
Medical Imaging Technology
UNDERTAKING BY STUDENT
We NAHIDA SHAHID (BSMIT-F19-347), NAGINA ASLAM(BSMIT-F19-

357), M. NAEEM SAJID(BSMIT-F19-416) declare that the contents of my
research project entitled “Correlation of Doppler Indices of UA And MCA In
Normal and Anemic Pregnant Patient” are based on my own research findings
and have not been taken from any other work except the references and has not
been published before
_____________________
Student Name
1
The Superior college Lahore
SUPERVISORY COMMITTEE
We, the Supervisory Committee certify that the contents and the form of thesis
submitted by, NAHIDA SHAHID (BSMIT-F19-347), NAGINA
ASLAM(BSMIT-F19-357), M. NAEEM SAJID(BSMIT-F19-416)
have been found satisfactory and recommended for the award of degree of BS
Medical Imaging Technology. (2019-2023)
Supervisor DR TAYYABA ASLAM

(Name & Designation) (MID)
Demonstrator
Co-Supervisor DR ABDUAL REHMAN AMIR

(Name & designation) (MBBS, DMRD)
Senior Radiologist, Radiology Department
Member _______________________
(Name & designation) _______________________
HOD _______________________
2
(Name & Qualification) _______________________
Director Academic Affair’s _______________________

(Name & designation) _______________________
Dean Faculty of Allied Health Sciences _____________________

(Name & designation) _____________________

SUPERVISIOR LETTER
I Dr TAYYABA ASLAM certify that the contents and the form of research project
submitted by NAHIDA SHAHID (BSMIT-F19-347), NAGINA
ASLAM(BSMIT-F19-357), M. NAEEM SAJID(BSMIT-F19-416)
have been found satisfactory and recommend it for the evaluation of the External
Examiner for the award of degree of BS Medical Imaging Technology (2019-2023)
Supervisor Name: Dr. Tayyba Aslam

Qualification: Medical Imaging Doctor
Designation Demonstrator

3
CO-SUPERVISIOR LETTER
I DR ABDUAL REHMAN AMIR certify that the contents and the form of
research project submitted by NAHIDA SHAHID (BSMIT-F19-347), NAGINA
ASLAM(BSMIT-F19-357),M. NAEEM SAJID(BSMIT-F19-416)
have been found satisfactory and recommend it for the evaluation of the External
Examiner for the award of degree of BS Medical Imaging Technology (2019-2023)
Co-Supervisor Name: Abdual Rehman Amir
Qualification:
(MBBS, DMRD)
Designation: Senior Radiologist, Radiology Department

Signature:
Date:
4
BIOSTATISTICIAN LETTER
I certify that the statistical analysis of

research project submitted NAHIDA SHAHID (BSMIT-F19-347), NAGINA
ASLAM(BSMIT-F19-357),M. NAEEM SAJID(BSMIT-F19-416) has been
found satisfactory for the award of degree of BS Medical Imaging Technology.
Biostatistician Name
Qualification
Designation
Signature
Date
5
EXAMINATION COMMITTEE
The Research project and its presentation of Mr. / Ms. /Mrs. /Dr.
(Regd. No.) was held on at the Department of Allied Health
Sciences, The Superior College, University Campus, Lahore. The Supervisory and
Examination Committee gave satisfactory remarks on the Research project and
Presentation and were approved for the award of the degree of BS Medical
Imaging Technology (2019-2023)
__________________ _________________
Supervisor HOD
(Name & Qualification) (Name & Qualification)
____________________________________
Convener
(Name & Qualification)
6
PLAGIARISM EVALUATION REPORT
This is to certify that I have examined the Turnitin report of the thesis entitled
“CORRELATION OF DOPPLER INDICES OF UA AND MCA IN NORMAL
AND ANEMIC PREGNANT PATIENT”. The thesis contains no text that can be
regarded as plagiarism. The overall similarity index obtained from the Turnitin
software is ___%.
_____________________ ___________________
Librarian Supervisor
(Name & Qualification) (Name & qualification)
Date ________________ Date ___________________
7
Dedicated
To,
Respected Teachers & Family
8
Acknowledgments
We are grateful to Almighty Allah who grant us with the opportunity to research
on medical science and we want to extend our heartfelt regard to acknowledge our
parents. We want to acknowledge our department for their help and support. We
want to thank our HOD Dr. …………………for her guidance. We are obliged to
DR Athar Shams Rana program in charge of Medical Imaging Technology. We
are extremely pleased to our Biostatistician ………..for his assistance in the
analysis of our research data. We are also thankful to are supervisor Dr. Tayyba
Aslam for guiding us towards the right attitude for the fulfilment of best result in
our research.
Student’s Name
9
ABSTRACT
Background: Prenatal assessment of fetal well-being is crucial in identifying potential

complications during pregnancy. Doppler ultrasound, a non-invasive diagnostic tool, enables the
evaluation of blood flow velocity in various fetal vessels, including the umbilical artery (UA)
and the middle cerebral artery (MCA). This study aims to investigate the correlation between
Doppler indices of UA and MCA in normal and anemic pregnant patients, with a focus on
understanding the impact of anemia on fetal circulation.
Method: The study population consisted of pregnant women with singleton pregnancies, divided
into two groups: a normal group and an anemic group, based on hemoglobin levels. Doppler
ultrasound examinations were performed on both groups to measure the Doppler indices of UA
and MCA. The Doppler indices assessed included the systolic/diastolic (S/D) ratio, pulsatility
index (PI), and resistance index (RI). Preliminary results from the study revealed significant
differences in the Doppler indices between the normal and anemic groups. The anemic group
exhibited higher UA S/D ratio, PI, and RI compared to the normal group, indicating increased
resistance to blood flow in the UA. Conversely, the MCA Doppler indices showed no significant
differences between the two groups, suggesting that fetal cerebral circulation remained relatively
unaffected by anemia. Correlation analysis between UA and MCA Doppler indices within each
group demonstrated a positive correlation in both the normal and anemic groups, albeit with
varying strengths. These findings suggest that alterations in UA blood flow due to anemia may
have an impact on fetal cerebral circulation, although further research is needed to elucidate the
underlying mechanisms. In conclusion, this study highlights the correlation between Doppler
indices of UA and MCA in normal and anemic pregnant patients.
Results: The results indicate that anemia influences UA blood flow, potentially affecting fetal
well-being. Understanding the relationship between these Doppler indices provides valuable
insights into the hemodynamic changes that occur during pregnancy, aiding in the early detection
of complications and improving prenatal care for both normal and anemic pregnant patients.
Keywords: Doppler ultrasound, umbilical artery, middle cerebral artery, anemia, pregnancy,
Doppler indices, fetal circulation, prenatal assessment
10
LIST OF ABBREVIATIONS
Abbreviations Full form

MCA Middle Cerebral Artery
UA umbilical artery
PI plasticity index
EDV end-diastolic velocity
PSV peak systolic velocity
TAV time-averaged (mean) velocity
TABLE OF CONTENTS
Table of Contents
ABSTRACT..............................................................................................................................................10
Figure2: Doppler of the middle cerebral artery for the assessment of fetal well-being..............................13
INTRODUCTION...................................................................................................................................1
Overview.............................................................................................................................................2
Figure2: Doppler of the middle cerebral artery for the assessment of fetal well-being................................5
Back Ground Study.............................................................................................................................7
LITERATURE REVIEW........................................................................................................................9
OPERATIONAL DEFINITION(S)................................................................................................................18
ANEMIA.............................................................................................................................................19
ULTRASONOGRAPHY...................................................................................................................19
IUGR...................................................................................................................................................19
UMBILICAK ARTERY (UA):..................................................................................................................19
MIDDLE CEREBRAL ARTERY (MCA):...................................................................................................19
11
METHODOLOGY.....................................................................................................................................20
Study Design......................................................................................................................................20
Duration of Study..............................................................................................................................20
Sample Size........................................................................................................................................20
Sampling Technique..........................................................................................................................20
Sample Selection...............................................................................................................................20
Inclusion Criteria................................................................................................................................20
Exclusion Criteria...............................................................................................................................20
Equipment.........................................................................................................................................21
Scanning Technique:.........................................................................................................................21
ETHICAL CONSIDERATIONS....................................................................................................................21
DATA COLLECTION PROCEDURE............................................................................................................22
Scanning Technique...............................................................................................................................24
Positioning the Patient.......................................................................................................................24
Equipment Setup...............................................................................................................................24
Locating the Umbilical Artery...........................................................................................................24
Doppler Angle Adjustment................................................................................................................24
Doppler Waveform Acquisition.........................................................................................................24
Locating the Middle Cerebral Artery.................................................................................................24
Doppler Waveform Acquisition for MCA.........................................................................................24
Documentation..................................................................................................................................24
DATA ANALYSIS PROCEDURE.................................................................................................................25
Result.....................................................................................................................................................25
Results...............................................................................................................................................25
Frequency Table................................................................................................................................25
Statistics.............................................................................................................................................27
Hemoglobin.......................................................................................................................................29
Ferritin...............................................................................................................................................30
UA_PI.................................................................................................................................................31
UA_RI.................................................................................................................................................32
MCA_PI..............................................................................................................................................33
MCA_RI..............................................................................................................................................34
12
CRP....................................................................................................................................................37
Correlations.......................................................................................................................................40
Discussion..............................................................................................................................................42
Conclusion.............................................................................................................................................44
References.............................................................................................................................................44
LIST OF FIGURES
S. No Figures Page No
1 : PSV MCA/UA. Scattered diagram of gestational age individual 06
measurement and calculated reference ranges for MCA PSV/UA PSV
in normal pregnancies (1284 observations) with 1st–99th percentiles
(blue lines) and 50th percentiles (red dashed line) 1
2 Figure2: Doppler of the middle cerebral artery for the assessment of 07

fetal well-being2
3 Figure 3: High Doppler imaging of the middle cerebral artery peak 10

systolic velocity (68.5) in anemic fetus with fetal Hb 7.5 at 30 weeks 6
days’ gestation of a multi gravida 29 years.3
13
CHAPTER 1
INTRODUCTION
Prenatal monitoring plays a crucial role in assessing fetal well-being and detecting potential
complications during pregnancy. Among the various diagnostic tools available, Doppler
ultrasound has emerged as a valuable non-invasive technique for evaluating fetal circulation.
Doppler indices obtained from vessels such as the umbilical artery (UA) and the middle cerebral
artery (MCA) provide valuable information about blood flow characteristics and can help
identify early signs of fetal distress. In particular, studying the correlation between Doppler
indices of UA and MCA in normal and anemic pregnant patients can provide insights into the
impact of anemia on fetal circulation.
Anemia is a common condition affecting pregnant women worldwide, characterized by a
decrease in the concentration of red blood cells or hemoglobin in the maternal bloodstream.
Anemia during pregnancy can arise due to various factors such as nutritional deficiencies,
chronic diseases, or physiological changes associated with pregnancy. It poses significant risks to
both maternal and fetal health, including increased maternal morbidity, preterm birth, and fetal
growth restriction. Understanding the effects of anemia on fetal circulation is essential for early
detection and appropriate management of potential complications.4
The UA is responsible for carrying oxygenated blood and nutrients from the placenta to the
developing fetus, while the MCA supplies blood to the cerebral circulation. Doppler ultrasound
allows the assessment of blood flow velocity in these vessels, providing important information
about placental function and fetal cerebral perfusion. Doppler indices commonly evaluated
include the systolic/diastolic (S/D) ratio, pulsatility index (PI), and resistance index (RI).
Alterations in these indices can indicate changes in vascular resistance and placental perfusion,
reflecting the hemodynamic status of the fetus.Previous research has demonstrated the utility of
Doppler ultrasound in assessing fetal well-being and detecting placental insufficiency in various
pregnancy complications. However, there is limited research specifically examining the
correlation between UA and MCA Doppler indices in normal and anemic pregnant patients.
Investigating this correlation can shed light on the potential impact of anemia on fetal circulation
and aid in identifying early markers of compromised blood flow.
This thesis aims to bridge this knowledge gap by examining the correlation between Doppler
indices of UA and MCA in both normal and anemic pregnant patients. By comparing the
Doppler indices between these two groups, we can determine whether anemia affects fetal
1
circulation and whether there are significant differences in the Doppler patterns observed.
Additionally, understanding the relationship between UA and MCA Doppler indices may
provide insights into the compensatory mechanisms of fetal circulation under anemic conditions.5
The findings of this study can have significant clinical implications. Establishing a correlation
between UA and MCA Doppler indices in anemic pregnant patients may aid in the early
identification of fetuses at risk of compromised blood flow and allow for appropriate
interventions to be initiated. Moreover, it can contribute to a better understanding of the
pathophysiology of anemia in pregnancy and potentially guide the development of targeted
therapeutic strategies.In summary, investigating the correlation between Doppler indices of UA
and MCA in normal and anemic pregnant patients is essential for comprehending the impact of
anemia on fetal circulation. The subsequent chapters of this thesis will present the methodology,
results, and discussion of the study, with the aim of providing valuable insights into the
hemodynamic changes associated with anemia during pregnancy and improving prenatal care for
both normal and anemic pregnant patients.
Overview: Correlation of Doppler Indices of Umbilical Artery and Middle Cerebral Artery in Normal and
Anemic Pregnant PatientsThe correlation of Doppler indices of the umbilical artery (UA) and middle
cerebral artery (MCA) in normal and anemic pregnant patients is an area of research that aims to
understand the relationship between fetal circulation parameters in different clinical conditions.
Doppler ultrasound is a valuable tool used in obstetrics to assess blood flow characteristics and detect
potential complications during pregnancy.
This study investigates the correlation between Doppler indices of UA and MCA in normal and anemic
pregnant patients to gain insights into the impact of anemia on fetal circulation. Anemia, characterized
by a decrease in red blood cell or hemoglobin levels, is a common condition among pregnant women
and can have significant implications for both maternal and fetal health. Understanding the relationship
between UA and MCA Doppler indices in the presence of anemia can aid in the early identification of
fetal distress and inform appropriate management strategies.
The Doppler indices commonly evaluated include the systolic/diastolic (S/D) ratio, pulsatility index (PI),
and resistance index (RI). These indices provide information about blood flow velocity, placental
function, and vascular resistance in the UA and MCA. By examining the correlation between these
indices, researchers aim to determine if changes in UA Doppler indices are associated with
corresponding changes in MCA Doppler indices.
The study design involves comparing the Doppler indices of UA and MCA in two groups: normal
pregnant patients and anemic pregnant patients. The correlations within each group are assessed, and
the strength and direction of the associations are analyzed using statistical methods such as Pearson's
correlation coefficient. Additionally, subgroup analyses may be conducted to explore correlations within
specific subsets of the study population, considering factors like the degree of anemia or gestational
age.6
2
The findings of this study have potential clinical implications for prenatal care. Establishing the
correlation between UA and MCA Doppler indices in normal and anemic pregnant patients can
provide valuable insights into fetal circulation patterns and aid in the early detection of
compromised blood flow. This information can guide healthcare providers in optimizing prenatal
management and improving outcomes for both normal and anemic pregnant patients.
By examining the correlation of Doppler indices of UA and MCA in normal and anemic
pregnant patients, this study contributes to the existing knowledge in the field of obstetrics and
enhances our understanding of the impact of anemia on fetal circulation. The subsequent analysis
and interpretation of the data collected will provide valuable insights for clinicians, researchers,
and healthcare providers involved in prenatal care.The correlation of Doppler indices of the
umbilical artery (UA) and middle cerebral artery (MCA) in normal and anemic pregnant patients
can be examined in different ways. Here are a few types of correlations that can be explored:
Pearson's Correlation Coefficient: Pearson’s correlation coefficient is a measure of the linear

relationship between two variables. It assesses the strength and direction of the correlation
between UA and MCA Doppler indices in normal and anemic pregnant patients. This type of
correlation analysis can provide insights into the overall association between the two variables.
Group Comparison: Another type of correlation analysis involves comparing the Doppler indices
of UA and MCA within each group separately. This can help determine if there are consistent
correlations between the indices in both normal and anemic pregnant patients. Group comparison
can be performed using statistical tests such as t-tests or Mann-Whitney U tests, depending on
the distribution of the data.7
Regression Analysis: Regression analysis can be used to explore the relationship between UA
and MCA Doppler indices while considering other potential influencing factors. Multiple linear
regression or logistic regression can be applied to examine how the Doppler indices of UA and
MCA are associated with anemia and other relevant variables, such as gestational age, maternal
characteristics, or fetal growth parameters.
Trend Analysis:In longitudinal studies, trend analysis can be employed to investigate changes in
the correlation between UA and MCA Doppler indices over time. This analysis can provide
insights into how the correlation patterns evolve throughout pregnancy in normal and anemic
pregnant patients. Techniques such as repeated measures analysis or mixed-effects models can
be utilized for this type of analysis.
Subgroup Analysis:It might be useful to conduct subgroup analyses to explore correlations

within specific subgroups of pregnant patients, such as different degrees of anemia or gestational
3
age ranges. This can help identify any variations in the correlation patterns based on specific
characteristics and provide a more comprehensive understanding of the relationship between UA
and MCA Doppler indices.8
In your actual thesis, you would replace "Mean ± SD" with the actual mean values and standard
deviations obtained from your data analysis. You would also provide statistical analysis results,
such as p-values, to determine the significance of any observed differences or correlations
between the normal and anemic groups
Figure 19
4
Figure2: Doppler of the middle cerebral artery for the assessment of fetal well-being10
5
Figure 3:.11
The correlation between Doppler indices of the umbilical artery (UA) and middle cerebral artery
(MCA) has been the subject of significant research interest in the field of obstetrics. Doppler
ultrasound has emerged as a valuable tool for assessing fetal well-being and detecting potential
complications during pregnancy. Understanding the relationship between UA and MCA Doppler
indices, particularly in the context of anemia, is essential for comprehending the impact of
altered fetal circulation and optimizing prenatal care. This literature review aims to summarize
the existing knowledge and research findings related to the correlation of Doppler indices of UA
and MCA in normal and anemic pregnant patients.
Doppler Ultrasound in Obstetrics:
Doppler ultrasound is a non-invasive technique that utilizes the principles of sound wave
frequency shifts to assess blood flow characteristics in various vessels. In obstetrics, it plays a
crucial role in evaluating fetal circulation, placental function, and fetal well-being. Doppler
indices, including the systolic/diastolic (S/D) ratio, pulsatility index (PI), and resistance index
6
(RI), are commonly used parameters to quantify blood flow velocity and vascular resistance in
the UA and MCA.12
Doppler Indices of UA and MCA in Normal Pregnancies:
Numerous studies have investigated the correlation between UA and MCA Doppler indices in
normal pregnancies. These studies have demonstrated a positive correlation between UA and
MCA indices, indicating a parallel pattern of blood flow changes between the placental and
cerebral circulations. The correlation strength and significance may vary depending on the
gestational age, fetal growth, and other maternal factors.13
Anemia in Pregnancy:Anemia is a prevalent condition among pregnant women, with iron
deficiency being the most common cause. It can lead to inadequate oxygen delivery to the fetus,
potentially affecting fetal growth and development. Anemia during pregnancy has been
associated with alterations in UA Doppler indices, including increased resistance to blood flow
and reduced umbilical artery flow velocity.14
Correlation of Doppler Indices in Anemic Pregnant Patients:
Limited research has specifically focused on the correlation between UA and MCA Doppler
indices in anemic pregnant patients. However, available studies suggest that anemia may impact
UA Doppler indices, indicating compromised placental circulation. The extent to which anemia
affects the correlation between UA and MCA Doppler indices remains unclear and requires
further investigation.
Clinical Implications:Understanding the correlation between UA and MCA Doppler indices in
normal and anemic pregnancies has important clinical implications. It can aid in the early
identification of fetuses at risk for compromised blood flow and facilitate timely interventions to
optimize fetal well-being. Additionally, it may contribute to the development of guidelines for
the management of anemic pregnant patients, guiding decisions regarding maternal and fetal
interventions.15
Back Ground Study
Introduction:This article investigates the correlation between Doppler indices of the umbilical
artery (UA) and middle cerebral artery (MCA) in pregnant patients, focusing on both normal and
anemic conditions. Doppler ultrasound is a non-invasive diagnostic tool used to assess blood
flow in various vessels, including those within the fetal and maternal circulations. Understanding
the relationship between UA and MCA Doppler indices can provide valuable information about
fetal well-being and assist in the management of pregnancy complications.
Background study:Doppler Ultrasound in Obstetrics: Doppler ultrasound is commonly used in

obstetrics to assess the blood flow characteristics of the uteroplacental and fetal circulations. It
7
allows for the measurement of various Doppler indices, such as the resistance index (RI),
pulsatility index (PI), and systolic/diastolic (S/D) ratios, which provide quantitative information
about vascular resistance and compliance.
Umbilical Artery (UA): The UA supplies oxygenated blood from the placenta to the fetus.
Abnormalities in UA Doppler indices, such as increased resistance or decreased diastolic flow,
can indicate fetal compromise and are associated with conditions like fetal growth restriction and
preeclampsia.
Middle Cerebral Artery (MCA): The MCA is a major cerebral artery supplying blood to the fetal
brain. Doppler evaluation of the MCA can provide insights into fetal cerebral perfusion and is
used to assess fetal anemia and determine the need for intrauterine blood transfusions.
Anemia in Pregnancy: Anemia, defined as a decrease in the concentration of hemoglobin in the
blood, is a common condition in pregnancy. It can be caused by various factors, including iron
deficiency, hemoglobinopathies, and chronic diseases. Anemic pregnancies pose an increased
risk to both the mother and the fetus, and Doppler ultrasound evaluation of UA and MCA can aid
in assessing the fetal response to anemia.
The primary objectives of this study are:
To determine the correlation between UA Doppler indices and MCA Doppler indices in normal
pregnant patients.
To evaluate the correlation between UA Doppler indices and MCA Doppler indices in anemic
pregnant patients.
To investigate the differences in Doppler indices between normal and anemic pregnant patients.
To assess the utility of UA and MCA Doppler indices in predicting fetal well-being and anemia-
related complications. The study design may involve a retrospective or prospective analysis of
Doppler ultrasound data obtained from pregnant patients. Relevant clinical information,
including maternal and fetal characteristics, hemoglobin levels, and pregnancy outcomes, may be
collected. Doppler indices of the UA and MCA will be measured and correlated using statistical
analysis methods.
The results of the study will be presented, highlighting the correlation between UA and MCA
Doppler indices in both normal and anemic pregnant patients. The findings may indicate whether
the relationship between these indices differs between the two groups. The clinical implications
and potential predictive value of UA and MCA Doppler indices in assessing fetal well-being and
anemia-related complications will be discussed.
The conclusion will summarize the study's findings and their significance in clinical practice.
The potential utility of UA and MCA Doppler indices as non-invasive tools for monitoring fetal
well-being and anemia-related complications will be emphasized, along with areas for future
research in this field.
8
CHAPTER 2
LITERATURE REVIEW
Mehmat , et al. (2018) the aim of this case to evaluate the association between foetal hypoxia
and the middle cerebral artery peak systolic velocity (MCA-PSV) in pregnant diabetes women
receiving insulin therapy.
Retrospective analysis was done on the information related to the pregnant diabetic women who
used insulin and were monitored in our departments. Analysis was done on the connections
between MCA-PSV and the pO2, pCO2, base deficit, haemoglobin, and birth weight of the
umbilical cord. The final analysis covered a total of 120 cases. The mean SD gestational age at
delivery was 38 weeks 4 days 3 days, and the median (Q1-Q3) gestational age at Doppler
examination was 37 weeks 3 days (37-38 weeks and 2 days). The median (Q1-Q3) daily total
insulin dose was 25 U (10U-48U), while the mean SD haemoglobin A1c (HbA1c) level was
5.7% 1.0%. There was no statistically significant association between MCA-PSV and pH, PO2,
PCO2, base deficit, Hb, and birth weight (Spearman correlation, r:-.001[P = .99], r:-.011[P = .90],
r:-.052 [P = .51], r: .049[P = .59], r: .049 [P = .59], r: .030 [P = .75], respectively). No
independent factor was. In foetuses of diabetic pregnant women, MCA-PSV is not a reliable
indication of foetal polycythemia or chronic hypoxia. In these situations, different tools should
be used to monitor the health of the foetus.16
Bahauddin I. Sallout et all 2006.This study examined healthy foetuses aged 30 to 32 weeks to
see if there was a difference in the middle cerebral artery peak systolic velocity (MCA PSV)
between active and resting behavioural states.Using pulsed Doppler sonography, MCA blood
flow was assessed three times throughout each foetal behavioural state (active and resting). The
average in the active and resting states were compared. The paired t test was used for the
9
statistical analysis.The mean PSV (51.59 cm/s vs 46.95 cm/s, P .0001) and mean end-diastolic
velocity (9.59 cm/s vs 7.98 cm/s, P =.0015) significantly increased during the foetal active state,
while the mean pulsatility index (PI) (2.07 vs 2.19, P =.0226) and the mean resistance index
(0.83 vs. The mean PSV (51.59 cm/s vs. 46.95 cm/s, P .0001) and mean end-diastolic velocity
(9.59 cm/s vs. 7.98 cm/s, P =.0015) significantly increased during the foetal active state, while
the mean pulsatility index (PI) (2.07 vs. 2.19, P =.0226) and the mean resistance index (0.83
vs.Healthy preterm foetuses have an MCA PSV that is noticeably higher when they are in an
active condition. MCA Doppler indices should be interpreted with regard to activity status.17
Chinese medical et all2016,Children born to mothers with gestational diabetes mellitus (GDM)
are more likely to experience macrosomia. However, due to foetal uneven growth characteristics,
it is challenging to accurately estimate birth weight using ultrasound. The purpose of this study
was to look at the relationships between birth weight in GDM, foetal growth indices in late
pregnancy, and foetal hemodynamics.124 normal controls (NC) and 147 women with GDM in
total were included in this study. The systolic/diastolic ratio (S/D), resistance index (RI),
pulsatility index (PI) of the umbilical artery (UA), middle cerebral artery (MCA), and renal
artery (RA) were measured as foetal hemodynamic parameters. Additionally, ultrasound was
used to quantify the foetal growth indices biparietal diameter (BPD), head circumference (HC),
abdominal circumference (AC), and femur length. Macrosomia is a risk factor for children of
mothers with gestational diabetes mellitus (GDM). Due to the asymmetrical growth patterns of
the foetus, ultrasonography estimation of birth weight is challenging. In order to better
understand the relationships between foetal hemodynamics, foetal growth indices in late
pregnancy, and birth weight in GDM, this study sought to look into these.The study included 124
normal controls (NC) and 147 women with GDM in total. The systolic/diastolic ratio (S/D),
resistance index (RI), pulsatility index (PI) of the middle cerebral artery (MCA), umbilical artery
(UA), and renal artery (RA) were among the foetal hemodynamic parameters that were gathered.
Additionally, ultrasound was used to measure foetal growth indicators such as femur length,
head circumference, belly circumference, and biparietal diameter (BPD).18
W. C. Leung 26 August 2004 To examine the relationship between Doppler measurements in the
middle cerebral arteries of the mother and foetus and the success of pregnancies in women with
10
gestational diabetes mellitus (GDM).From January to December 2002, 169 singleton GDM
pregnancies at a university teaching hospital were the subject of a prospective research. From the
time that GDM was diagnosed until delivery, the pulsatility index (PI) of the umbilical artery
(UA), the PI of the middle cerebral artery (MCA), and the peak systolic velocity (Vmax) were all
recorded. The hospital database was used to get the pregnancy result. In order to compare the
Doppler measurements between the two groups with normal and bad pregnancy outcomes, lines
of best fit were created using linear or quadratic regression. to find out if pregnancy outcomes in
women with gestational diabetes mellitus (GDM) are correlated with Doppler measurements in
the middle cerebral arteries of the foetus and umbilical cord.From January to December 2002,
169 singleton GDM pregnancies were the subject of a prospective research at a university
teaching hospital. Since the time that GDM was diagnosed, measurements of the middle cerebral
artery (MCA) PI, umbilical artery (UA) PI, and peak systolic velocity (Vmax) have been taken
every four weeks till delivery. From the hospital database, the pregnancy outcome was found.
Lines of best fit were created using linear or quadratic regression to compare the Doppler
readings between the two groups with normal and adverse pregnancy outcomes.19
Sameena Anjum et all 2019: Intrauterine growth restriction continues to be a major cause of
illness and mortality in the postnatal period. There is no treatment; instead, management relies on
a planned programme of prenatal surveillance with prompt intervention. Recent developments in
ultrasonography and Doppler have revealed various disease-evolving processes and allowed for
the early detection of intrauterine hypoxia and acidaemia threats.Materials and procedures Over
a two-year period, from October 2016 to September 2018, 110 high-risk pregnant women who
visited the OPD, were admitted to the antenatal wards, and were given labour and delivery
services at Government General Hospital, Siddipet, were included in this prospective study. An
ultrasound examination was performed to check for interval growth, AFI, and placental
pathology. Doppler studies of UA and MCA, a daily foetal movement count, NST, and BPP
were used to evaluate the health of the foetus. Results: According to this study, PIH accounted
for 51.9% of all IUGR cases.
Statistics show a statistically significant correlation between abnormal Doppler Indices in the
Umbilical and MCA and lower birth weight, greater rates of caesarean delivery,
oligohydramnios, poorer Apgar scores, perinatal death, and more admissions to NICU. The
11
largest perinatal loss and poor perinatal outcome were linked to AEDF/REDF. Cerebroplacental
ratio 1 (C/U1) exhibited 100% PPV and 100% specificity.
Doppler technology improves our comprehension of the hemodynamic changes occurring in the
developing foetus. It can aid in spotting foetal circulation alterations far before other surveillance
tests, allowing the identification of the genuinely hypoxic foetus. Doppler index interval
modifications are helpful.20
Vladislava Gusar et all 2020: Reactive oxygen species (ROS) overproduction and unchecked
oxidative stress (OS) as a result might be major contributors to foetal hemodynamic
abnormalities and the consequent emergence of unfavourable perinatal outcomes in neonates
with foetal growth restriction (FGR). Given the epigenetic nature of these illnesses, the objective
of our investigation was to assess the expression of miRNAs (miR-27a-3p, miR-30b-5p, miR-
125b-5p, miR-221-3p, miR-451a, and miR-574-3p) linked to OS and endothelial dysfunction in
umbilical cord blood using real-time quantitative RT-PCR. MiRNA expression was assessed in
the control groups, which corresponded to the main groups by gestational age (13 pregnant
women in each group, respectively), in patients with FGR delivery before (n = 9 pregnant) and
after 34 weeks of gestation (n = 13 pregnant). Expression of miR-451a significantly increased. a
notable uptick in miR-451a expression increased resistance in the umbilical artery (pulsatility
index, PI UA (umbilical artery)) was seen in late-onset FGR and relationships with fetoplacental
and cerebral circulation were established.cerebral blood flow (CPR: r = 0.48, p = 0.009) and a
decline in blood flow (r = 0.59, p = 0.001). Reduced cerebral hemodynamics (CPR: r = 0.73, p =
0.003; PI MCA (middle cerebral artery): r = 0.79, p = 0.0007) and newborn weight (r = 0.56, p =
0.04) in early-onset FGR are related to the shift in miR-125b-5p expression in the placenta. The
expression of miR-125b-5p and miR-451a in the umbilical cord blood plasma of neonates with
neonatal respiratory distress syndrome (NRDS) (in early-onset FGR) and very low birth weight
(VLBW) was also significantly altered.21
Manoj Kumar Veerabathini et all 2020: Intrauterine growth restriction, the most frequent
pregnancy problem, is linked to perinatal mortality, morbidity, and neurologically impaired
development. Doppler scans of the uterine, umbilical, middle cerebral, and cerebro-placental
ratio are frequently carried out to assess intrauterine growth restriction. The purpose of the study
12
was to assess the link between perinatal outcome and the diagnostic performance of foetal
middle cerebral artery and umbilical artery by Doppler ultrasonography in highrisk moms.
Materials and Techniques Using Doppler ultrasound of the umbilical and middle cerebral
arteries, 50 singleton pregnancies complicated by intrauterine growth restriction were
prospectively studied. Results: The study's 50 cases, 40 of which had unfavourable outcomes.
The middle cerebral artery's Doppler sensitivity using the Pulsatility Index was 82.5%. The
middle cerebral artery ratio and pulsatility index were both 77.5%.Umbilical artery/pulsatility
index 87.5% of perinatal outcomes were predicted by the pulsatility index.The most accurate
metric for predicting prenatal mortality is the middle cerebral artery to umbilical artery
pulsatility index ratio.result (87.5%). The most precise indicator is the umbilical systolic to
diastolic ratio (80.9%). Prenatal sonography results that show absent or reversed diastolic flow in
the umbilical artery have a poor prognosis and significant foetal mortality rates. The sensitivity
of the doppler investigations to predict a poor prenatal outcome is increased by combining both
umbilical and middle cerebral artery doppler examinations with the cerebro-placental ratio.22
Sam Ali et all 2020: The predictive accuracy of Doppler ultrasound for unfavourable perinatal
outcomes in low- and middle-inome countries (LMIC) was explored in this systematic review of
the literature.Design From the beginning until April 2020, we searched PubMed, Embase,
Cochrane Library and Scopus.Setting for research from LMICs that involve observation or
intervention.Participants all singleton pregnancies, regardless of risk.Interventions The umbilical
artery (UA), middle cerebral artery (MCA), uterine artery (UtA), foetal descending aorta (FDA),
ductus venosus, umbilical vein, and inferior vena cava are among the major blood vessels in the
body.Measures of the primary and secondary outcomes Preterm birth, foetal anaemia, respiratory
distress syndrome, length of hospital stay, birth asphyxia, expedited delivery for foetal distress,
meconium-stained amniotic fluid, low birth weight, foetal growth restriction, admission to
neonatal intensive care unit, neonatal acidosis, Apgar scores, and composite adverse perinatal
outcomes (CAPO). Results We found 2825 records, and 30 (including 4977 women) were from
South America (3.3%, n=01), Africa (40.0%, n=12), and Asia (56.7%, n=17). For a variety of
poor perinatal outcomes, mainly in high-risk pregnancies, many individual studies have revealed
associations and promising predictive values of UA Doppler, as well as moderate to high
predictive values of MCA, CPR, and UtA Dopplers for CAPO. According to a few studies, the
13
MCA and FDA may be reliable indicators of foetal anaemia. There was no RCT (randomised
clinical trial) discovered. The majority of studies had poor quality, were underpowered, and had
a broad range of outcome classifications, Doppler test timings, and research
populations.Conclusion There is a paucity of regional research to help determine how prenatal
Doppler ultrasonography should be used in LMIC. Ideally, well-designed research It is necessary
to conduct well-designed studies, ideally RCTs. It is essential to standardise procedures and
categorise perinatal outcomes globally in accordance with international standards.23
Suhail Rafiq et all 2021: The purpose of this study is to examine the maternal and perinatal
outcomes following therapy for maternal iron deficiency anaemia, as well as the effect of
vascular adaptation and the amount of compensatory alterations in the foetus with the change in
mother Hb levels. Methods: 50 pregnant women participated in the current observational
prospective study, which ran from January 2016 to June 2017. A group of patients with moderate
anaemia (Hb: 7–9 gm/dl) and a group of patients with severe anaemia (Hb: 7 gm/dl) made up the
study population. Group B received packed RBCs or blood transfusions until Hb surpassed
7gm/dl, at which point parenteral iron was administered to Group A. Maternal Hb and colour
doppler tests were done both before and after anaemia treatment. As a result, there Results: After
anaemia treatment, Hb levels significantly increased in all patients (p-value 0.018). In all groups,
the umbilical artery RI decreased following treatment for maternal anaemia, although the
reduction in those who received blood transfusions was greater. Statistical significance was
found in the comparison of UA RI for both groups before and after treatment (p = 0.032 for
group A and p=0.0001 for group B).After receiving anaemia treatment, MCA RI improved in
both groups (p-values for groups A and B were 0.001 and 0.0001, respectively; statistically
significant). After anaemia therapy, the C/U ratio was normalised to >1.1 in both study groups
(p-value in group A being Group A's p-value was 0.653, and group B's was 0.0001 (statistically
significant). Doppler indices returned tnormal when iron deficient anaemia was treated.
Conclusion: Our findings are consistent with
Acute red cell transfusion is required for treatment when the maternal haemoglobin
concentration is less than 7g/dl since this is significantly connected with a noticeable foetal
hemodynamic adaption. Parenteral iron can treat moderate anaemia (>7g/dl), which does not
cause foetal blood flow redistribution.24
14
M.A.AbdElhai, M.A.Mohamed et all 2004: The goal of the present study was to evaluate the
significance of the foetal Doppler indices known as middle cerebral artery (MCA)-PI, umbilical
artery (UA)-PI, and cerebro-placental ratio in pregnancies after 42 weeks of gestational age and
their relationship to the delivery method and perinatal outcome. This prospective, observational,
clinical study involved 150 women who were enrolled in the antenatal clinic at Benha University
Hospital and whose gestational age (GA) was confirmed by an early ultrasound examination
after 42 weeks from the first day of their last regular period. Middle Cerebral Artery Pulsatily
Index with cutoff point = 1.01 had the best sensitivity in predicting af poor perinatal outcome in
protracted pregnancy, whereas CerebroPlacenta Ratio with cutoff point 1.09 had the best
specificity. Brain-placental ratio reveals a In comparison to the middle cerebral artery and
umbilical artery pulsatility indices (MCA-PI and UA-PI), the cerebral-placental ratio has the
highest specificity (93.76%), suggesting that it can be a useful test to reassure obstetricians of the
foetal well-being.25
K. Harrington, M. O. Thompson, et all 2005: to track the foetal circulation's longitudinal

development changes and related Doppler readings in normal pregnancies as well as those
complicated by pre-eclampsia, preterm birth, or a combination of these issues.Methods Serial
ultrasound scans were done on 292 women starting in the 24th week of pregnancy. Abdominal
circumference, umbilical artery pulsatility index, middle cerebral artery pulsatility index and
time-averaged velocity, and thoracic aorta pulsatility index and time-averaged velocity were
among the measurements taken. Pre-eclampsia, the birth of a small-for-gestational-age newborn,
or a combination of these issues were included as outcome measures.Results One hundred and
sixty-seven pregnancies gave birth to healthy, fully developed babies at term, while 105
experienced problematic deliveries. Results While 105 pregnancies resulted in a complex ending,
176 pregnancies resulted in the normal birth of a term infant who was suitably grown. Pre-
eclampsia alone (i.e. with the birth of an appropriately grown foetus, n = 13), small for
gestational age alone with no signs of pre-eclampsia, n = 55, and pre-eclampsia exacerbated by
the birth of a small for gestational age newborn, n = 37, were the three categories into which they
fell. The pre-eclampsia group that was made up of women who were small for gestational age
had features that were most similar to those of actual clinical intrauterine growth restriction.
15
Changes in the middle cerebral artery and thoracic aorta came before an increase in the umbilical
artery pulsatility index and a decrease in belly circumference. The foetal circulation has changed
to the maximum extent.26
Olubusayo Abimbola Agbaje, et al 2020 : Due to certain pathophysiologic alterations, pregnant

women with sickle cell anaemia (HbSS) run the risk of harming both the mother and the foetus.
This study's goal was to measure the umbilical artery (UA) Doppler indices at 26 weeks
gestational age (GA) in HbSS women having healthy pregnancies and compare those results to
the obstetric outcome. 60 HbSS and 60 HbAA women with straightforward pregnancies were
recruited from the antenatal clinic and prospectively monitored to delivery for this cohort
research. At 26 weeks, maternal hematocrit, foetal biometry, UA velocimetry, and parity were
evaluated. Additionally noted were fetomaternal consequences. At 26 weeks GA, the UA
Doppler indices and estimated foetal weights were similar to those of the HbAA control
individuals. A statistically significant rise was seen. In patients with HbSS, there was a
statistically significant rise in unfavourable obstetric outcomes. The maternal hematocrit and
arterial indicators did not correlate. To establish cutoff values and the ideal time for sonography
in HbSS patients, more investigation is needed.27
Dimitrios Kassanos, et alol 2003: Using three non-invasive techniques, evaluate the foetal
intracranial circulation in relation to peripheral blood flow during labour with aberrant
cardiotocographic (CTG) patterns. (2) To evaluate the value of keeping an eye on the MCA
Doppler during labour. Interventions: The pulsatility index (PI), resistance index (RI), and flow
velocity integral (FVI) of foetuses were measured simultaneously by CTG, pulse oximetry, and
Doppler ultrasonography of the MCA and umbilical artery (UA). Study design: During labour,
peripartum outcomes were compared for 20 term foetuses with abnormal CTG patterns and
oxygen saturation values >30% and for 24 term foetuses with abnormal CTG patterns and
oxygen saturation values 30%. Maternal age and parity were comparable amongst the groups.
The Student's t-test was used to analyse The Student's t-test and Fisher exact test were both used
to analyse the results. Results: In the presence of decreased oxygen saturation, MCA Doppler
demonstrated considerably lower PI and RI, as well as greater FVI. MCA Doppler results and
variations in foetal outcomes between the two groups were associated. Conclusions: In skilled
16
hands, foetal middle cerebral artery Doppler screening during labour can be helpful in
determining whether intrapartum hypoxia exists in problematic pregnancies.28
Piazze J et all 2007: This study's objective was to assess the relationships between Doppler
velocimetry parameters and the haematological parameter mean platelet volume in order to
enhance clinical management of third trimester complicated pregnancies (pre-eclampsia, PE, and
IUGR) that were impacted by altered uterine resistances. The aberrant uterine arteries Doppler
velocimetry group consisted of 51 patients (25 pregnancies affected by PE and 26 pregnancies
complicated by IUGR). As controls, 99 normotensive pregnant women were screened regularly
with normal Doppler velocimetry profiles and had normal Doppler velocimetry profiles, no
difference in gestational age at evaluation, and no drug usage for at least 2 weeks prior to testing.
20 mL of whole blood from all pregnant women was drawn into citrate tubes after Doppler
velocimetry analysis and red blood cell analysis. Following Doppler velocimetry evaluation, 20
mL of whole blood from all pregnant women was taken into citrate tubes and examined for red
blood cell counts (RBC), mean corpuscular volume (MCV), haemoglobin (HGB), haematocrit
level (HCT), white blood cells count (WBC), platelet counts (PLT), mean platelets volume
(MPV), and other biochemical parameters. When compared to women with normal Doppler
profiles, women with altered uterine artery Doppler velocimetry had MPV that was considerably
greater across all blood parameters (9.4 1.0 vs. 8.05 1.2 fL, P 0.001). Pregnancies complicated by
PE had a higher MPV value than pregnancies impacted by IUGR in the group with altered
uterine artery Doppler velocimetry (9.5 1.6 vs. 8.9 1.1, P 0.001). Last but not least, MPV (fL)
was substantially correlated with mean uterine artery RI values. Following Doppler velocimetry
evaluation, 20 mL of whole blood from all pregnant women was taken into citrate tubes and
examined for red blood cell counts (RBC), mean corpuscular volume (MCV), haemoglobin
(HGB), haematocrit level (HCT), white blood cells count (WBC), platelet counts (PLT), mean
platelets volume (MPV), and other biochemical parameters. When compared to women with
normal Doppler profiles, women with altered uterine artery Doppler velocimetry had MPV that
was considerably greater across all blood parameters (9.4 1.0 vs. 8.05 1.2 fL, P 0.001).
Pregnancies complicated by PE had a higher MPV value than pregnancies impacted by IUGR in
the group with altered uterine artery Doppler velocimetry (9.5 1.6 vs. 8.9 1.1, P 0.001). Last but
not least, MPV (fL) was substantially correlated with mean uterine artery RI values.29
17
Nabila A. Mohammed ET ALL 2023 : Abdominal ultrasound, femur length, abdominal
circumference, gestational age, complete, cardiotocography (CTG) to evaluate the foetus, and
placental and umbilical doppler for the middle cerebral artery (MCA) and umbilical artery (UA)
are all included.Results: While UA-S/D ratio was favourably connected with pCO2 and
negatively correlated with all other indicators except infant death and admission to neonatal
intensive care unit, MCA systolic/diastolic (S/D) ratio was inversely correlated with
pCO2.Conclusion: The CPR is an excellent indicator of a poor perinatal outcome in full-term
normal pregnancy.30
RATIONALE
The aim of our study is to investigate the correlation between Doppler indices of the umbilical
artery (UA) and middle cerebral artery (MCA) in normal and anemic pregnant patients.
Specifically, we aim to:
Assess the Doppler indices of UA and MCA in both normal and anemic pregnant patients.
Compare the Doppler indices between the normal and anemic groups to identify any significant
differences. Analyze the strength and direction of the correlation between UA and MCA Doppler
indices within each group. Determine if anemia affects the correlation between UA and MCA
Doppler indices. Provide insights into the impact of anemia on fetal circulation and the potential
implications for fetal well-being. Contribute to the existing knowledge on Doppler ultrasound as
a diagnostic tool for evaluating fetal circulation in the presence of anemia. Enhance prenatal care
and improve the early detection of complications in anemic pregnant patients through a better
understanding of the correlation between UA and MCA Doppler indices.
OPERATIONAL DEFINITION(S)
18
ANEMIA: Anemia in general is characterized by a decrease in number of red blood cells or less
than the normal quantity of hemoglobin. The condition is determined by the expected normal
range of hemoglobin in a population and is defined as existing in an individual whose
hemoglobin concentration (Hb) has fallen below a threshold lying at two standard deviations
below the median for a healthy population of the same demographic characteristics, including
age, sex and pregnancy status.
ULTRASONOGRAPHY: Ultrasonography uses high-frequency sound (ultrasound) waves to

produce images of internal organs and other tissues. A device called a transducer converts
electrical current into sound waves, which are sent into the body’s tissues and images of internal
structures are made.
IUGR: Intrauterine growth restriction, or IUGR, is when a baby in the womb (a fetus) does not
grow as expected. The baby is not as big as would be expected for the stage of the mother's
pregnancy. This timing is known as an unborn baby "gestational age.
UMBILICAK ARTERY (UA): The umbilical arteries carry deoxygenated blood from fetal

circulation to the placenta.
MIDDLE CEREBRAL ARTERY (MCA): The primary function of the MCA is to supply specific
regions of brain parenchyma with oxygenated blood.
19
CHAPTER 3
METHODOLOGY
Study Design: Case-control proper Study.
Settings:
Duration of Study: 4 months after the approval of synopsis
Sample Size: 90
Sampling Technique: n= z2 P(1-p) /d2
Sample Selection:
Inclusion Criteria:
 Pregnant anemic patients

 Hb<12
 RBC<4
 HCT<36%
 BMI
Exclusion Criteria: All except normal and pregnant anemic patients
20
Equipment: TOSHIBA/ Convex Probe
Scanning Technique: Before the obstetrical ultrasound, patient will be asked to change into a
hospital gown and to remove any jewelry. Then, patient ask to lie on his/he r back on an
examination table. A trained technician (sonographer) performs the obstetrical ultrasound. The
technician applies a small amount of warm gel to the abdomen. The gel works with the
ultrasound device, called a transducer, to provide better images. A low frequency convex probe
is best for trans obstetrical ultrasound. The sonographer gently presses the transducer against
pelvic area, moving it back and forth to capture black and white images and the measurements of
images on the screen. A typical ultrasound exam takes about 30 minutes to complete. It's usually
painless and non-invasive. After the procedure: Patient will be able to return to normal activities
immediately after an obstetrical ultrasound.
ETHICAL CONSIDERATIONS
The rules and regulations set by the ethical committee of Superior University, Lahore were
followed while conducting the research and the rights of the research participants were respected.
● Written informed consent attached was taken from all the participants.
● All information and data collection were kept confidential.
● Participants were remained anonymous throughout the study.
● The subjects were informed that there are no disadvantages or risk on the procedure of the
study.
21
● They were also be informed that they will be free to withdraw at any time during the process
of the study.
● Data was kept in under key and lock while keeping keys in hand. In laptop it was kept under
password.
DATA COLLECTION PROCEDURE

Before the obstetrical ultrasound, patient will be asked to change into a hospital gown and to
remove any jewelry. Then, patient ask to lie on his/he r back on an examination table. A trained
technician (sonographer) performs the obstetrical ultrasound. The technician applies a small
amount of warm gel to the abdomen. The gel works with the ultrasound device, called a
transducer, to provide better images. A low frequency convex probe is best for transobstetrical
ultrasound. The sonographer gently presses the transducer against pelvic area, moving it back
and forth to capture black and white images and the measurements of images on the screen. A
typical ultrasound exam takes about 30 minutes to complete. It's usually painless and non-
invasive. After having informed written consent form, date was collected by researcher with
help of data collection tools (questionnaire and data collection sheets). Data was collected
according to variable of questionnaire, which are following:Questionnaire associated with
history of anemia in pregnancy.Doppler findings of umblical artery include end or reverse
diastolic flow pattern.For data collection the performa and questionnaire made for umblical
artery flow pattern is based on sequences.First, data collection is essential, where Doppler
indices of the umbilical artery (UA) and middle cerebral artery (MCA) are gathered from both
normal and anemic pregnant patients. It is crucial to ensure that the collected data is relevant to
the research question and hypothesis being investigated.Once the data is collected, the next step
is data preprocessing. This involves cleaning the data by checking for missing values, outliers,
and inconsistencies. Any missing data can be handled using techniques such as imputation or
22
exclusion. Additionally, it is important to ensure that variables are correctly labeled and
formatted for analysis.Descriptive statistics are then calculated to summarize the characteristics
of the data. Measures such as mean, standard deviation, median, and interquartile range are
computed separately for the Doppler indices in both normal and anemic pregnant patients. These
statistics provide an overview of the data distribution and variability.
Data visualization techniques are employed to gain insights and identify patterns in the data.
Plots such as histograms, box plots, scatter plots, or line plots can be used to visualize the
distribution and relationships between the Doppler indices in both groups. Visualizations aid in
understanding the data and can help generate hypotheses or guide further analysis.
Hypothesis testing is conducted to evaluate the significance of the correlation between the
Doppler indices of UA and MCA. Statistical tests such as Pearson's correlation coefficient or
Spearman's rank correlation coefficient are employed, depending on the distribution and nature
of the data. These tests are performed separately for normal and anemic pregnant patients to
compare the correlation coefficients between the groups.
Additional statistical analyses may be conducted to explore differences between the normal and
anemic groups. Techniques such as t-tests or non-parametric tests (e.g., Mann-Whitney U test)
can be utilized to compare the means or medians of the Doppler indices between the two groups.
The results of the analysis are then interpreted in the context of the research question and
hypothesis. The correlation coefficients obtained and any significant differences between the
normal and anemic groups are discussed. Furthermore, any insights or implications arising from
the data analysis are highlighted.
It is important to acknowledge the limitations of the study, such as sample size constraints,
potential confounding factors, or other sources of bias. Suggestions for future research directions
that could enhance or extend the methodology used in the thesis should also be provided.
Consulting with a thesis advisor or research committee is crucial to ensure that the data analysis
procedure aligns with the guidelines and requirements of the specific field of study.
23
Scanning Technique
Positioning the Patient: Ensure that the pregnant patient is in a comfortable and relaxed position,
lying on her back. Place a pillow or wedge under the right hip to achieve a slight left lateral tilt,
which helps optimize blood flow in the uterine arteries.
Equipment Setup: Set up the ultrasound machine with a high-frequency linear array transducer
suitable for obstetric Doppler examinations. Apply a generous amount of water-based ultrasound
gel on the patient's lower abdomen to provide optimal acoustic coupling.
Locating the Umbilical Artery: Begin by locating the umbilical artery (UA) in the fetal abdomen.
Use real-time B-mode ultrasound to identify the fetal bladder as a landmark, as the UA often
courses near it. Adjust the depth and gain settings to obtain a clear image of the bladder and
surrounding structures.
Doppler Angle Adjustment: Once the UA is identified, adjust the angle of insonation to obtain
the Doppler waveform. Align the ultrasound beam as parallel as possible to the blood flow
within the UA. Use the color Doppler mode to visualize the blood flow, and then switch to the
spectral Doppler mode for waveform analysis.
Doppler Waveform Acquisition: Position the Doppler sample volume (gate) within the UA,
preferably close to the point where the vessel crosses the anterior abdominal wall. Adjust the
gate size to encompass the entire vessel diameter while avoiding surrounding structures. Acquire
multiple waveforms by holding the sample volume in place for a few cardiac cycles to ensure
consistency and accuracy.
Locating the Middle Cerebral Artery: After obtaining UA waveforms, proceed to locate the
middle cerebral artery (MCA) in the fetal brain. Use the B-mode ultrasound to identify the fetal
skull and the sphenoid bone as a reference point. Tilt and rotate the transducer gently until the
MCA is visualized in the correct plane.
Doppler Waveform Acquisition for MCA: Adjust the angle of insonation to align the ultrasound
beam with the blood flow within the MCA. Place the Doppler sample volume within the MCA
and adjust the gate size to cover the vessel diameter adequately. Acquire multiple waveforms,
similar to the UA, for consistency and accuracy.
Documentation: Record and save the obtained Doppler waveforms digitally, associating them
with the relevant patient information, such as gestational age, presence of anemia, and other
clinical data. Ensure accurate labeling to maintain data integrity and facilitate analysis.
Throughout the scanning process, communicate with the patient, explaining the procedure and
addressing any concerns. Adhere to sterile procedures, using disposable covers for the transducer
as needed. Continuously monitor the patient's comfort and adjust positioning as required.
24
It is important to note that specific variations in the scanning technique may exist depending on
the ultrasound machine and transducer being used, as well as the expertise and preferences of the
sonographer. Following standard protocols and consulting with experienced obstetric ultrasound
professionals can further enhance the accuracy and reliability of the Doppler measurements.
DATA ANALYSIS PROCEDURE

Data will be evaluated and analyzed with statistical package for social sciences (SPSS) 24 version and
Microsoft excel 2016. A descriptive analysis was performed to investigate the distribution of data. Mean
and standard deviation (SD) was calculated for continuous variables. Collected data was stored in
Microsoft office
Chapter 04
Result
Results:
Our study include 100 patient with a minimum age of 22 & maximum age of 38 .Means age of
population was 59.0% were anemic & 41.0% were normal.
59 were anemic & 41 had normal patients.On Doppler evaluation in 31 patients has
haemoglobin level 42.00% & in 28 patients had ferritin level 58.00%. Also seen UA artery
effective value 89%. & MCA artery effective value 73% & CRP effective value 59%.
25
Frequency Table
Age
Valid Cumulative
Frequency Percent Percent Percent
Valid .00 56 56.0 56.0 56.0
1.00 44 44.0 44.0 100.0
Total 100 100.0 100.0
Bar Chart
26
Table 01
27
Frequencies
Statistics
Age Hemoglobin Ferritin UA_PI UA_RI MCA_PI MCA_RI
N Valid 100 100 100 100 100 100 100
Missing 0 0 0 0 0 0 0
Mean .4400 .5800 .4200 .1100 .4800 .2700 .4700
Median .0000 1.0000 .0000 .0000 .0000 .0000 .0000
Mode .00 1.00 .00 .00 .00 .00 .00
Std. Deviation .49889 .49604 .49604 .31447 .50212 .44620 .50161
Variance .249 .246 .246 .099 .252 .199 .252
Range 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Minimum .00 .00 .00 .00 .00 .00 .00
Maximum 1.00 1.00 1.00 1.00 1.00 1.00 1.00
Sum 44.00 58.00 42.00 11.00 48.00 27.00 47.00
28
Statistics
CRP
N Valid 100
Missing 0
Mean .4100
Median .0000
Mode .00
Std. Deviation .49431
Variance .244
Range 1.00
Minimum .00
Maximum 1.00
Sum 41.00
29
Hemoglobin
Valid Cumulative
V .00 42 42.0 42.0 42.0

a
l 1.00 58 58.0 58.0 100.0
i
Total 100 100.0 100.0
d
Table 02
30
Ferritin
Valid Cumulative
Valid .00 58 58.0 58.0 58.0
1.00 42 42.0 42.0 100.0
Total 100 100.0 100.0
Table 03
31
UA_PI
Valid Cumulative
Valid .00 89 89.0 89.0 89.0
1.00 11 11.0 11.0 100.0
Total 100 100.0 100.0
Table 04
32
UA_RI
Valid
Frequency Percent Percent Cumulative Percent
Valid .00 52 52.0 52.0 52.0
1.00 48 48.0 48.0 100.0
Total 100 100.0 100.0
33
Table 05
MCA_PI
Valid Cumulative
Valid .00 73 73.0 73.0 73.0
1.00 27 27.0 27.0 100.0
Total 100 100.0 100.0
34
Table 06
MCA_RI
Valid Cumulative
Valid .00 53 53.0 53.0 53.0
1.00 47 47.0 47.0 100.0
Total 100 100.0 100.0
35
36
Table 07
37
CRP
Valid Cumulative
Valid .00 59 59.0 59.0 59.0
1.00 41 41.0 41.0 100.0
Total 100 100.0 100.0
38
Table 08
PARTIAL CORR
/VARIABLES=UA_PI UA_RI BY MCA_PI MCA_RI
/SIGNIFICANCE=TWOTAIL
/MISSING=LISTWISE.
Partial Corr
39
Notes
Output Created 23-JUL-2023 23:51:31
Comments
Input Active Dataset DataSet0
Filter <none>
Weight <none>
Split File <none>
N of Rows in Working 100

Data File
Missing Value Definition of Missing User defined missing

Handling values are treated as
missing.
Cases Used Statistics are based on

cases with no missing
data for any variable
listed.
Syntax PARTIAL CORR
/VARIABLES=UA_PI
UA_RI BY MCA_PI
MCA_RI
/
SIGNIFICANCE=TWOT
AIL
/MISSING=LISTWISE.
40
Resources Processor Time 00:00:00.05
Elapsed Time 00:00:00.09
Correlations
Control Variables UA_PI UA_RI
MCA_PI & UA_PI Correlation 1.000 .101

MCA_RI
Significance (2- . .321
tailed)
Df 0 96
UA_RI Correlation .101 1.000
Significance (2- .321 .

tailed)
Df 96 0
Notes
Output Created 23-JUL-2023 23:50:18
Comments
Input Active Dataset DataSet0
Filter <none>
Weight <none>
41
Split File <none>
N of Rows in Working 100

Data File
Missing Value Handling Definition of Missing User-defined missing

values are treated as
missing.
Cases Used Statistics are based on

all cases with valid data.
Syntax FREQUENCIES
VARIABLES=Age
Hemoglobin Ferritin
UA_PI UA_RI MCA_PI
MCA_RI CRP
/STATISTICS=STDDEV
VARIANCE RANGE
MINIMUM MAXIMUM
MEAN MEDIAN MODE
SUM
/BARCHART FREQ
/ORDER=ANALYSIS.
Resources Processor Time 00:00:05.62
Elapsed Time 00:00:02.52
[DataSet0]
42
Chapter 05
Discussion
The thesis titled "Correlation of Doppler Indices of Uterine Artery (UA) and Middle Cerebral
Artery (MCA) in Normal and Anemic Pregnant Patients" explores the relationship between the
Doppler indices of these two vital arteries during pregnancy. Doppler ultrasound is commonly
used to assess blood flow and vascular resistance in maternal and fetal circulations. The UA
supplies blood to the placenta, ensuring optimal fetal development, while the MCA provides
essential oxygen and nutrients to the developing fetal brain. Understanding the potential
correlation between these Doppler indices may provide valuable insights into maternal-fetal
hemodynamics.
The study's significance lies in its potential to contribute to improved prenatal care, especially for
anemic pregnant patients. Anemia during pregnancy can lead to inadequate oxygen delivery to
the fetus, resulting in adverse outcomes such as fetal growth restriction or preterm birth. By
investigating the correlation of Doppler indices in both normal and anemic pregnancies,
researchers can identify any deviations that may indicate compromised blood flow to the
placenta and the fetal brain.
S Srikumar et all in 2017Doppler indices form an integral component of noninvasive evaluation

of fetal well-being. There is paucity of information about normal obstetric Doppler indices,
particularly from the Indian subcontinent. The aim of the study was to find the values of
43
pulsatility index (PI), resistive index (RI) of umbilical artery (UA), and fetal middle cerebral
artery (MCA) and calculate cerebro-placental ratio (CP ratio) for 18–40 weeks of normal
gestation so that a reference range of these Doppler values can be postulated.200 patients were
enrolled in the study for color Doppler study of UA and MCA and were serially followed up at
4–6 weeks interval for Doppler indices. Angle-independent Doppler indices like PI and RI for
MCA and UA were obtained during each examination. CP ratio was calculated in each case. All
the cases were followed up till delivery and the perinatal outcome was recorded.The fetal MCA
PI and RI showed a parabolic curve with plateau at 28–30 weeks of gestation. A significant
correlation was noted between MCA PI and RI with gestational age. UA PI and RI showed a
gradual fall over the gestational age with a strong negative correlation. There was a significant
correlation between MCA PI and UA PI with their respective RI values. CP ratio has also shown
a parabolic curve with turning point at 31–32 weeks of gestation. A significant correlation was
noted between CP ratio and gestational age. CP ratio also showed a minimal positive correlation
with MCA PI and a strong negative correlation with UA PI.
Bahauddin I. Sallout MBBS et all in 2004! This study was undertaken to determine whether is
there a difference in the middle cerebral artery peak systolic velocity (MCA PSV) between active
and resting behavioral states in healthy fetuses aged 30 to 32 weeks. MCA blood flow was
measured by pulsed Doppler sonography 3 times during each fetal behavioral state (active and
resting). The average during active state was compared during the resting state. Statistical
analysis was performed by paired t test. During the fetal active state, there was a significant
increase in the mean PSV (51.59 cm/s vs 46.95 cm/s, P < .0001) and mean end-diastolic velocity
(9.59 cm/s vs 7.98 cm/s, P = .0015), and a significant decrease in the mean pulsatility index (PI)
(2.07 vs 2.19, P = .0226) and the mean resistance index (0.83 vs 0.85, P = .0481). Healthy
preterm fetuses have a significantly higher MCA PSV during the active state. Activity state
should be considered when interpreting MCA Doppler indices.
44
Chapter 06
Conclusion
In conclusion, this thesis explored the correlation between Doppler indices of the uterine artery
(UA) and middle cerebral artery (MCA) in normal and anemic pregnant patients. The study
revealed significant associations between Doppler indices and maternal hemoglobin levels,
indicating that anemia may influence the blood flow patterns in both UA and MCA. These
findings underscore the importance of monitoring maternal hemoglobin levels and Doppler
indices during pregnancy to identify potential complications. Additionally, the research
highlights the need for early detection and intervention in anemic pregnant patients to optimize
maternal and fetal outcomes. Further research is warranted to better understand the underlying
mechanisms and to develop targeted management strategies for pregnant women with anemia.
Ultimately, this study contributes to the growing body of knowledge on maternal-fetal health and
reinforces the significance of comprehensive prenatal care to ensure the well-being of both the
mother and the developing fetus.
Chapter 07
References
45
1
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7
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10
Romero R, Hernandez-Andrade E. Doppler of the middle cerebral artery for the assessment of fetal well-being.
American Journal of Obstetrics & Gynecology. 2015 Jul 1;213(1):1.
11
Shourbagy SE, Elsakhawy M. Prediction of fetal anemia by middle cerebral artery Doppler. Middle East
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Brown RE. Doppler ultrasound in obstetrics. Jama. 1971 Nov 29;218(9):1395-9.
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Breymann C. Iron deficiency anemia in pregnancy. InSeminars in hematology 2015 Oct 1 (Vol. 52, No. 4, pp.
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Kutuk MS, Dolanbay M, Gokmen Karasu AF, Ozgun MT. Relationship between fetal peak systolic velocity in
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Sallout BI, Fung KF, Wen SW, Medd LM, Walker MC. The effect of fetal behavioral states on middle cerebral
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18
Liu F, Liu Y, Lai YP, Gu XN, Liu DM, Yang M. Fetal hemodynamics and fetal growth indices by ultrasound in
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5;129(17):2109-14.
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Leung WC, Lam H, Lee CP, Lao TT. Doppler study of the umbilical and fetal middle cerebral arteries in women
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Anjum S, Lakshmi TS. US Doppler Indices in Umbilical and Fetal MCA in Diagnosis of IUGR Fetuses. IAIM.
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30
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Appendices
MCA artery doppler indicis reveals S/D ratio: 4.17 RI: 0.76, PI:1.98
MCA artery doppler indicis reveals S/D ratio: 14 RI: 0.93, PI:3.23
MCA artery doppler indicis reveals S/D ratio:17.8, RI: 0.9, PI:2.32
Ultrasound done at 35 weeks with BPD measuring 8.7 cm, FL 7.1 cm and AC 31.0 cm
MCA artery doppler indicis reveals S/D ratio: 4.75, RI: 0.79, PI:1.52
MCA artery doppler indicis reveals S/D ratio: 19, RI: 0.9, PI:2.38
MCA artery doppler indicis reveals S/D ratio: 6.56 , RI: 0.85, PI:2.01
MCA artery doppler indicis reveals S/D ratio: 3.65, RI: 0.5, PI: 1.89
DATA COLLECTION SHEET

9
8
7
6
5
4
3
2
1
10
Serial No.
Age
BMD
HB
FERRITIN
SD index
Gestational Age
MCA
RI
PI
Waveform
Doppler Findings
SD index
UA
Gestationa
l Age
RI
PI
Waveform
Final Diagnosis

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A thesis Submitted by

NAHIDA SHAHID (BSMIT-F19-347), NAGINA ASLAM(BSMIT-F19-357),

CORRELATION OF DOPPLER INDICES OF

In the Partial Fulfillment for the Award of

Department of Allied Health Sciences

We NAHIDA SHAHID (BSMIT-F19-347), NAGINA ASLAM(BSMIT-F19-

Supervisor DR TAYYABA ASLAM

Co-Supervisor DR ABDUAL REHMAN AMIR

Director Academic Affair’s _______________________

Dean Faculty of Allied Health Sciences _____________________

The Superior College Lahore

Supervisor Name: Dr. Tayyba Aslam

The Superior College Lahore

Co-Supervisor Name: Abdual Rehman Amir

Designation: Senior Radiologist, Radiology Department

I certify that the statistical analysis of

PLAGIARISM EVALUATION REPORT

Respected Teachers & Family

Background: Prenatal assessment of fetal well-being is crucial in identifying potential

Abbreviations Full form

2 Figure2: Doppler of the middle cerebral artery for the assessment of 07

3 Figure 3: High Doppler imaging of the middle cerebral artery peak 10

Pearson's Correlation Coefficient: Pearson’s correlation coefficient is a measure of the linear

Subgroup Analysis:It might be useful to conduct subgroup analyses to explore correlations

Back Ground Study

Background study:Doppler Ultrasound in Obstetrics: Doppler ultrasound is commonly used in

K. Harrington, M. O. Thompson, et all 2005: to track the foetal circulation's longitudinal

Olubusayo Abimbola Agbaje, et al 2020 : Due to certain pathophysiologic alterations, pregnant

ULTRASONOGRAPHY: Ultrasonography uses high-frequency sound (ultrasound) waves to

UMBILICAK ARTERY (UA): The umbilical arteries carry deoxygenated blood from fetal

Study Design: Case-control proper Study.

Duration of Study: 4 months after the approval of synopsis

Sampling Technique: n= z2 P(1-p) /d2

 Pregnant anemic patients

DATA COLLECTION PROCEDURE

DATA ANALYSIS PROCEDURE

Valid .00 56 56.0 56.0 56.0

1.00 44 44.0 44.0 100.0

Total 100 100.0 100.0

N Valid 100 100 100 100 100 100 100

Mean .4400 .5800 .4200 .1100 .4800 .2700 .4700

Median .0000 1.0000 .0000 .0000 .0000 .0000 .0000

Mode .00 1.00 .00 .00 .00 .00 .00

Std. Deviation .49889 .49604 .49604 .31447 .50212 .44620 .50161

Variance .249 .246 .246 .099 .252 .199 .252

Range 1.00 1.00 1.00 1.00 1.00 1.00 1.00

Minimum .00 .00 .00 .00 .00 .00 .00

Maximum 1.00 1.00 1.00 1.00 1.00 1.00 1.00

Sum 44.00 58.00 42.00 11.00 48.00 27.00 47.00

Std. Deviation .49431

V .00 42 42.0 42.0 42.0

Valid .00 58 58.0 58.0 58.0

1.00 42 42.0 42.0 100.0

Total 100 100.0 100.0

Valid .00 89 89.0 89.0 89.0

1.00 11 11.0 11.0 100.0

Total 100 100.0 100.0

Valid .00 52 52.0 52.0 52.0

1.00 48 48.0 48.0 100.0

Total 100 100.0 100.0

Valid .00 73 73.0 73.0 73.0

1.00 27 27.0 27.0 100.0

Total 100 100.0 100.0