FETAL DOPPLER ASSESSMENT IN

PREGNANCY
BY
BODE ADEWUNMI
 INTRODUCTION
• The use of Doppler in perinatal medicine can be
divided into two component
• Uterine artery Doppler(uteroplacental Doppler and
fetal arterial and venous Doppler
• Uterine artery Doppler is usually performed as
screening test
• Fetal Dopplers are used as an adjunct to diagnosing
the severity of fetal compromise in potentially hypoxic
conditions and are often performed serially in fetus
that is though to be high risk.
 UMBILICAL ARTERY
•UB artery waveform represents placenta vascular resistance
•Should be regarded as indicator of resistance in the feto-
placental vascular bed
•UB artery circulation is a low impedance circulation with increase
amount of end-diastolic flow with advancing gestation .
•Increase in end-diastolic flow that is seen with advancing
gestation is a direct result of increase in the number of tertiary
stem villi that takes place with placental maturation.
•Disease that obliterate small muscular arteries in the placenta
tertiary stem villi result in a progressive decrease in end diastolic
flow in the UB artery Doppler waveform until absent and then
reverse flow during diastole is noted
•Reversed diastolic flow in UB artery represents advanced
stage of placental compromise.
•Absent or reversed end-diastolic flow in the umbilical artery
is commonly associated with severe intrauterine growth
restriction (IUGR) and oligohydramnios.
•Umbilical artery waveforms can be obtained from a free loop
of umbilical cord, in most cases near the placental insertion
where movement artifact is les.
•Angle should be less than 600.
•From 16wks onwards ,the UA should show positive End
Diastolic velocity.
•At 30-34wks delivery decisions in a growth restricted baby
may be made on the basis of amniotic fluid ,fetal
movements ,CTG and umbilical artery Doppler.
•From 16wks onwards ,the UA should show positive
End Diastolic velocity.
•At 30-34wks delivery decisions in a growth restricted
baby may be made on the basis of amniotic fluid ,fetal
movements ,CTG and umbilical artery Doppler.
Note; that absents or reversed umbilical artery end-
diastolic flow suggests more detailed investigation in
units where fetal Doppler is available or close
observation and investigation using a
cardiotocography.
*Three major abnormalities of UA
1. Raised resistance, pulsatality index PI or resistance
index >95 percentile
 MIDDLE CEREBRAL ARTERY.

•MCA is the most accessible cerebral vessel to ultrasound

imaging in the fetus .
•It carries more than 50% of cerebral blood flow .
•The cerebral circulation is normally a high impedance
circulation with forward flow throughout the cardiac circle.
• In the presence of fetal hypoxemia central redistribution of
blood flow occur resulting in an increased blood flow to the
brain, heart and adrenals and a reduction in flow to the
peripheral and placental circulation.
The blood flow redistribution is known as the brain sparing
reflex and plays a major role in fetal adaptation to oxygen
deprivation
•Fetal heads is visualized in BPD section and probe
TILTED to allow visualization of the greater wing of
the sphenoid bone.
•The course of the MCA follows the wing of the
sphenoid bone, allowing it to be seen easily on color
flow Doppler.
•The Anterior vessel is insonated with pulsed Doppler
in segment nearest to the circle of wilis
•Care should be taken to avoid pressure with the
transducer on the fetal head, it can increase the MCA
PI transiently.
•It is usually seen in transverse plane.
•The normal MCA is characterized by high peak systolic
velocity and low diastolic velocity
•Normal MCA waveform from 22-28weeks shows
little or no EDF.
•It is not uncommon to see a little reverse flow in
health fetus.
•From 28-34wks a little EDF is often seen, but this is
normal.
•After 34wks Physiological redistribution may occur
owing to changes in flow through the heart leading to
relatively deoxygenated blood being shunted to the
cerebral circulation
•In hypoxia, there is a progressive reduction in
resistance in the MCA.
•In cases of chronic fetal hypoxia, the blood volume in
the fetal circulation is redistributed in favor of vital
important organs like the heart, kidneys and brain.
•Vasodilatation of MCA with increase in diastolic flow
and corresponding hyperperfusion is considered
pathologic.
•If hypoxia persists, the flow will return to normal
level. this reflect a terminal decompensation in the
setting of acidemia or brain edema
 UTERINE ARTERY.
• Pregnancy is associated with physiologic changes at
the level of the uterine vasculature which result in a
progressive decrease in impedance with advancing
gestation.
• The maternal adaptation to pregnancy is thought to
result from the trophoblastic invasion of the
maternal spiral arterioles in the first half of
pregnancy.
• The invaded maternal spiral arterioles rendered
maximally dilated and minimally responsible to the
sympathetic and para-sysphathetic systems.
• The adaptation is intended to ensure a sustained
increase in blood flow to the uterus during
pregnancy.
•The uterine artery is unique among vessels in that it has a
remarkable ability to increase its capacity.
•The blood flows through the non-pregnant uterine artery is
roughly 40ml on each side, but this increase to ten fold to
400ml by late pregnancy.
•In the second and third trimester of pregnancy, the uterine
artery is usually insonated over its apparent crossover the
external iliac artery.
Three abnormalities of uterine artery flow are
*High mean resistance >95th percentile for RI and PI.
*Unilateral uterine artery notch.
*Bilateral uterine artery notches.
*Uterine artery waveforms may exhibit a low resistance
pattern.
• Uterine artery screening is commonly carried out at 20-
24weeks gestation.
At this stage, the second move of trophoblast invasion is
complete and those women will abnormal waveforms either
high resistance or bilateral uterine artery notches are at high
risk of developing the complication of impaired
placentation.
-These complication are pre-eclampsia, fetal growth
restriction, intra uterine death or placental abruption.
NOTE: Uterine artery notches are present in almost all women
at conception and most in early pregnancy, they should
disappear by 24weeks.
 DUCTUS VENOSUS
• DV is easily identified by its turbulent flow.
• The DV conveys approximaly 50% to 60% of
oxygen rich blood from the placenta to the right
atrium via the umbilical vein and inferior vena
cava and to the left atrium via foramen ovale
• The ductus venosus is most easily visualized in
the transverse scan through the fetal epigastrium
• Three antegrade wave are visible in the DV
waveform
• The S wave caused by ventricular contraction, the D
wave caused by passive ventricular filling and a
wave caused by atrial contraction
• NOTE- all disturbances of cardiac hemodynamics
that occurs in association with tricuspid
insufficiency lead to a steady decline in the diastolic
flow and ultimately diastolic reverse flow.
• These disturbances include anemia, placental
insufficiency, arrhythmias e.t.c.
• Reverse flow in the DV is again associated with
abnormal CTG and increased perinatal mortality.
• Color duplex scanning of DV is particularly
important in cases of significant growth retardation
 with abnormal arterial waveform.
• Doppler of DV can be a very helpful study in cases
where there is a steady deterioration of fetal
condition and an impending risk of preterm birth
<35weeks
• If DV is still normal it can be managed. if reverse
flow is found or abnormal CTG changes arises, the
fetus should be delivered by cesarean section
THANK YOU