ROLE OF DOPPLER IN OBSTETRICS

BENEFIT OF DOPPLER
DOPPLER IN LOW RISK PREGNANCY
 DOES NOT FOUND TO BE COST EFFECTIVE

DOPPLER IN HIGH RISK PREGNANCY

 IT IS A NON INVASIVE METHOD OF SCREENING FOR COMPLICATIONS LIKE
EARLY ONSET PREECLAMPSIA ,IUGR
 MATERNAL DOPPLER

 FETOPLACENTAL DOPPLER

 FETAL DOPPLER
 Uterine artery DOPPLER
 UTERINE BLOOD FLOW RISES FROM 50ML/MNT TO 500-700ML/MNT AT TERM

 RESISTENCE TO FLOW IN UTERINE ARTERY DECREASES WITH GESTATION.

 IN NORMAL PREGNANACY ,DOPPLER WAVEFORM PERSISITENT EDF - CONTINUED FLOW

THROUGH OUT CARDIAC CYCLE

 AS GA ADVANCES UTEROPLACENTAL CIRCULATION BECOMES HIGH FLOW LOW RESISTENCE

SYSTEM : GREATER EDF

 TROPHOBLASTIC INVASION AND PERSISTING HORMONAL EFFECT

 UTERINE ARTERY DOPPLER IS A BIOPHYSICAL MARKER OF PLACENTAL FUNCTION

 AN EARLY DIASTOLIC NOTCH IN UA AT 12-14 WKS – DELAY IN TROPHOBLASTIC INVASION

AT 24 WKS PERSISTENT NOTCH IS CONFIRMATORY EVIDENCE OF ABNORMAL TROPHOBLASTIC INVASION

 AN ABNORMAL UTERINE ARTERY WAVEFORM (UAPI >95th CENTILE,WITH OR WITOUT

THE PRESENCE OF UNI OR B/L NOTCHING)IN FIRST AND SECOND TRIMESTER

PARTICULARY ASSOCIATED WITH PREECLAMPSIA AND FGR.

 IN PREDICTION OF PREECLAMPSIA SENSITIVITY IS 47.8%,SPECIFICITY 92.1%

 IN EARLY ONSET IUGR 39.2% AND 93.1 RESPECTIVELY

 IMPLICATION
 RCOG RECCOMENDATION(GREEN TOP GUIDLINE NO 31) FOR SCREENING OF FETUSES

AT RISK OF GR,UTERINE ARTERY DOPPLER AT 20-24 WKS.

 IF ABNORMAL, SERIAL ULTRASOUND MEASURMENT OF FETAL SIZE AND FETAL WELL

BEING WITH UMBILICAL ARTERY DOPPLER COMMNECING AT 26-28 WKS

 IN ABNORMAL UA DOPPLER COUNSELLING SHOULD DONE ON PERFORMING FETAL

CICK COUNTS,AND REPORTING SYMPTOMPS OF PREECLAMPSIA

 START LOW DOSE ASPIRIN

PREDICTIVE VALUE OF UA DOPPLER IN IUGR :IF ABNORMAL
 6 TIMES CHANCE OF PREECLAMPSIA
 3 TIMES CHANCE OF IUGR
 2 TIMES CHANCE OF PERINATAL DEATH.
ROLE OF DOPPLER IN IUGR
 IMPLICATIONS OF IUGR
ANTEPARTUM
INTRAPARTUM ORGAN DAMAGE AND DEATH
PERIPARTUM
LONG TERM SEQUELE BRAIN DAMAGE
METABOLIC SYNDROME

SO WITH THE HELP OF DOPPLER WE CAN PREVENT

LONG TERM COMPLICATIONS OF IUGR
 PATHOPHYSIOLOGY

 IN PLACENTAL DYSFUNCTION;TROPHOBLASTIC INVASION IS CONFINED TO DECIDUAL

PORTION OF MYOMETRIUM

 (NO TRANSFORMATION OF SPIRAL AND RADIAL ARTERIES TO LOW RESISTENCE SYSTEM)

 ALTERED EXPRESSION OF VASOACTIVE SUBSTANCES CAUSES INADEQUATE HYPOXIA

STIMULATED ANGIOGENESIS

 MATERNAL PLACENTAL FLOOR INFACTS,FETAL VILLOUS OBLITERATION AND FIBROSIS

 INCREASE PLACENTAL BLOOD FLOW RESISTENCE

 UMBILICAL ARTERY
DOPPLER

 UMBILICAL ARTERY DOPPLER VELOCIMETRY IS CONSIDERED STANDARD IN THE

EVALUATION AND MANAGEMENT OF GROWTH RESTRICTED FETUS

 FLOW THROGHOUT THE CARDIAC CYCLE

 PLACENTAL RESISTENCE DECREASES AS GA ADVANCES AS GA ADVANCES WHICH IS

REFLECTED AS INCREASE IN DF

 AT 20 WKS S/D RATIO IS 4

 AT 30 WKS < 3

 AT TERM 2
 ABSENT OR REVERSED EDF UNIQUELY LINKED WITH FGR

 ABNORMAL UA DOPPLER VELOCIMETRY COMBINED WITH EFW OF

<3rd PERCENTILE IS MOST STRONGLY ASSOCIATED WITH POOR
OBSTETRICAL OUTCOME.
MIDDLE CEREBRAL ARTERY
DOPPLER
 HIGHLY PULSATILE FLOW
HIGHER IMPEDENCE WITH NORMALLY DECREASED DIASTOLIC
FLOW

 RESPONSES OF FETAL TRUNK AND CEREBRAL CIRCULATION TO

HYPOXEMIA IS DIFFERENT

 PERIPHERAL ARTERIES CONSTRICTS AND TRUNCAL RESISTENCE

INCREASES – HIND LIMB REFLEX

 BRAIN SPARING EFFECT – CEREBRAL VASODILATATION

DOPPLER IN FETAL HYPOXIA
 ASPHYXIA = HYPOXIA + METABOLIC ACIDOSIS

 IN HYPOXIA FETAL ADAPTIVE CHANGES OCCURE PRIOR TO DECOMPENSATION

– BRAIN SPARING EFFECT
 CEPHALISATION OF BLOOD FLOW ; DILATED CEREBRAL VASCULATURE;
DECREASE PI OF MCA
 IN PROLONGED HYPOXIA ; CEREBRAL RESISTENCE INCREASE ; INCREASE IN
PI OF MCA(METABOLIC ACIDOSIS)
 UMBILICAL ARTERY DOPPLER ; INCREASE S/D RATIO
 INCREASE PI
 ABSENT/REVERSED EDF
LATE ONSET IUGR

 IN THIS TYPE OF PLACENTAL DYSFUNCTION ,BLOOD PERFUSION CAN

BE NORMAL AND THE PREDOMINANT FEATURE IS AN ABNORMAL

DIFFUSION OF OXYGEN ACROSS VILLOUS MEMBRANE.

 DECREASE IN OXYGEN TRANSFER ASSOCIATED WITH DECREASE IN

MCA FLOW RESISTENCE AND DECREASE IN CO2 CLEARANCE

INCRESES MCA PSV

 LATE ONSET FGR LITTLE CHANGE IN UA DOPPLER

CEREBROPLACENTAL RATIO

 RATIO OF MCA PI/UA PI

 A DECRESING CPR SUGESTS FETAL COMPROMISE, AND CORRELATES

BETTER WITH ADVERSE OUTCOME COMPARED TO ITS INDIVIDUAL

MEASURMENTS.

 MOST SENSITIVE DOPPLER AT 28-34 WKS

 A CPR VALUE< 1 INDIACTES 11 TIMES ADVRESE PERINATAL OUTCOME

 DUCTUS VENOSUS DOPPLER
 THE MOST COMMONLY USED VENOUS DOPPLER

 IT REFLECTS FETAL CARDIAC FUNCTION

 FOUR PHASE WAVEFORM IMPORTANT IN REGULATING DISTRIBUTION OF

OXYGEN AND NUTRITION

 HIGHER RESISTENCE IN VENOUS CIRCULATION REFLECTS THE INCRESING

AFTERLOAD OF THE RIGHT HEART AND INCREASING IV PRESSURE CAUSED
BY HYPOXIA OF THE FETAL MYOCARDIUM-FETAL ACIDOSIS
CHANGES IN DV WAVEFORM

 ABSENT A WAVE
REVERSED A WAVE

 SIGNIFIES HEART FAILURE AND

CARDIAC DECOMPENSATION

 MORE DEEPER MORE CHANCE OF

ASPHYXIA
TRUFFLE STUDY

 A STUDY ON 542 WOMEN AT 26-32 WKS OF GA WITH VERY PRETERM GR ALLOCATED TO

DELIVER ON THE BASIS OF ABNORMAL CTG,EARLY DV CHANGES ( PI >95 TH

PERCENTILE),LATE DV CHANGES

 PRIMARY OUTCOME OF SURVIVAL WITHOUT NEUROIMPAIRMENT DID NOT DIFFER,BUT

INTERVENTION BASED ON CHNAGES IN DV WAVEFORM MIGHT PRODUCE IMPROVEMENT

AT 2 YRS
 SEQUENCE OF EVENTS IN IUGR

 ABSENT UA END DIASTOLIC FLOW

 ABNORMAL DOPPLER FLOW STUDY OF MCA( PI)
 DUCTUS VENOSUS : ABSENT / REVERSED A WAVE
 REVERSED FLOW IN UA
EFW< 10TH ASPHYXIA IS EXTEREMLY RARE DELIVERY AT 38 WKS OF GA
PERCENTILE,INCREASED UAPI INCREASED RISK FOR EARLIER DELIVERY FOR
NORMAL MCA AND CPR INTRAPARTUM DISTRESS MATERNAL AND OBSTETRICAL
NORMAL VEINS HISTORY
BPS > 8/10 EARLY ONSET IUGR ;DOPPLER
AFV NORMAL EVERY 2 WKS,WKLY BPS
LATE ONSET IUGR WKLY
DOPPLER AND BPS

EFW, 10TH BLOOD FLOW REDISTRIBUTION EARLY ONSET FGR ; WKLY

PERCENTILE,INCREASES UAPI HYPOXEMIA POSSIBLE DOPPLER AND BPS
LOW MCA PI ,LOW CPR ASPHYXIA RARE LATE ONSET FGR 2-3 TIMES/WK
NORMAL VEINS INCREASED INTRAPARTUM DOPPLER AND BPS
BPS>8/10 DISTRESS
AFV NORMAL
UA A/R EDV HYPOXEMIA IS COMMON ADMISSION; 2-3 TIMES/WK
NORMAL VEINS ASPHYXIA POSSIBLE DOPPLER,DAILY BPS
BPS 6/10 ONSET OF FETAL COMPROMISE IF UA REDV >30 WKS DELIVERY
OLIGOHYDRAMNIOS IF UA AEDV >32WKS DELIVERY
<34 WKS ANTENATAL STEROIDS
<32 WKS MGSO4

SIGNIFICANT REDISTRIBUTION HYPOXEMIA COMMON ADMISSION

PRESENT ASPHYXIA LIKELY INDIVIDUALISED TESTING
INCREASED DV PULSATILITY PROVEN FETAL COMPROMISE DAILY
( 95TH CENTILE) < 34 WKS STEROIDS
BPS <4/10 <32 WKS MGSO4
OLIGOHYDRAMNIOS

ABSENT / REVERSED DV a FETAL DECOMPENSATION >26 WKS DELIVER AT

WAVE IMMINENT STILL BIRTH TERITIARY CARE CENTRE WITH
PULSATILE UMBILICAL VEIN PERINATAL MORTALITY NEWBORN CARE
BPS<4/10 IRRESPECTIVE OF
OLIGOHYDRAMNIOS INTERVENTION
 Fetal anaemia

 PSV IN MCA IS MEASURED

 VELOCITY OF BLOOD FLOW IS INCRESED IN A BRAIN OF FETUS

WITH ANAEMIA
 MORE PSV MORE ANAEMIA (MCA PSV >1.5 MoM IN MODERATE TO
SEVERE ANEMIA)
 THE MOST RELIABLE NON INVASIVE TEST FOR PREDICTING FETAL
ANAEMIA
 SENSITIVITY 100%
 MANAGEMENT N FETAL ANEMIA

 LESS THAN 1.29 MoM REPEAT US EVERY 10-14 DAYS TILL 34-35 WKS

 PSV 1.29- 1.5 MoM ,REPEAT EVERY 2-7 DAYS

 PSV >1.5 MoM, TERMINATION SHOULD BE DONE

 FETAL AORTA

 LESS COMMONLY USED ARTERIAL MEASUREMENT

 REFLECTS BALANCE BETWEEN RIGHT AND LEFT VENTRICLE

OP

 NORMALLY FORWARD FLOW IN DIASTOLE

 IN FGR RETROGRADE FLOW IN DIASTOLE

 TECHNICALLY DIFFICULT TO SAMPLE

 RENAL ARTERY
 UNTIL 34 WKS OF GA DIASTOLIC FLOW IS ABSENT PHYSIOLOGICALY

 INCREASE FLOW WITH GA( DECREASE PI ), DECREASE IMPEDENCE

 IN OLIGOHYDRAMNIOS DUE TO IUGR OR POST TERM PREGNANCY

DECREASE IN RENAL PERFUSION EXPLAINED BY BRAIN SPARING EFFECT

 COLOR DOPPLER CAN BE DONE FOR RENAL MALFORMATIONS

RENAL ARTERY WITH ABSENT
DIASTOLIC FLOW
RENAL MALFORMATIONS
AGENESIS
HORSESHOE KIDNEY
MORBDLY ADHERENT PLACENTA
 DUE TO PARTIAL OR TOTAL ABSENCE OF DECIDUA BASALIS

AND IMPERFECT DEVELOPMENT OF NITABUCH MEMBRANE

 DIAGNOSED BY SONOGRAPHY

 ACCRETE SYNDROME IS SUSPECTED IF UTERINE SEROSAL-

BLADDER WALL INTERFACE AND THE RP VESSELS

MEASURES <1mm AND LARGE INTRAPLACENTAL LACUNAE.

 ECTOPIC PREGNANCY

 TUBAL ECTOPIC PREGNANCY CONSTITUTES 95% OF ECTOPIC

 ABSENT INTRAUTERINE GESTATIONAL SAC WITH ADNEXAL
LESION WITH B HCG > 3000mIU/ml
 PSEUDOGESTATIONAL SAC
Pseudogestaional sac In ectopic
pregnancy
EXTRAOVARIAN ADNEXAL
MASS WITH PERIPHERAL
RING OF VASCULARITY
FETAL ECHOCARDIOGRAPHY
INDICATIONS OFFETAL ECHOCARDIOGRAPHY
 AUTO IMMUNE AB
 IVF( 4 TIMES)
 METABOLIC DIASEASE
 TERATOGEN EXPOSURE
 ABNORMAL CARDIAC SCREENING IN FETUS(18-22 WKS)
 ABNORMAL FETAL HR
 HYDROPS
 INCREASED NT
 MONOCHORIONIC TWINS
THREE VESSEL VIEW
 CONCLUSION
 DOPPLER REFLECTS INTRAUTERINE FETAL ENVIRONMENT

 DOPPLER IS AN IMPORTANT MODALITY IN PREDICTING

IUGR,PREECLAMPSIA

 IT HAS AN IMPORTANT ROLE IN DECIDING THE PROGRESS AND

PROGNOSIS OF FGR FETUS,THUS IMPORTANT ROLE IN
MANAGEMENT DECISIONS
TO OPTIMISE THE TIMING OF DELIVERY – IN THE
PRESCENCE OF IATROGENIC PREMATURITY IN ONE
HAND AND IMPENDING FETAL DEATH ON THE
OTHER HAND
REFERNCES
 WILLIAMS OBSTETRICS
 HIGH RISK PREGNANCY DAVID JAMES
 HIGH RISK PREGNANCY AND DELIVERY
THANK YOU