宫内生长受限胎儿的主动脉峡部血流指数和围产儿不良结局的关系

目的探讨主动脉峡部(aortic isthmus,AOI)的峡部血流指数(isthmic flow index,IFI)与宫内生长受限(IUGR)胎儿围产结局的关系。方法收集IUGR胎儿41例,采集胎儿大脑中动脉(MCA)、脐动脉(UA)、静脉导管(DV)及AOI血流频谱并随访所有病例,分析多普勒血流指数与围产儿结局的相关关系。结果 IUGR胎儿的围产期不良结局与AOI-IFI显著相关(95%,0.003～0.608),AOI-IFI评估IUGR胎儿围产结局的灵敏度62%、特异度95%。结论 AOI-IFI是IUGR胎儿围产期不良结局的独立预测因子,对于评估其围产结局的灵敏度及特异度均很高,揭示胎儿AOI血流成像在IUGR胎儿临床管理及监测中的潜在价值。     

彩色多普勒超声检测子宫动脉及脐动脉在晚发型宫内生长受限中的价值

目的：彩色多普勒超声检测母体子宫动脉和胎儿脐动脉在晚发型宫内生长受限的血流动力学价值及预测不良围产儿结局。 方法：分析晚发型宫内生长受限的孕妇169例和58例同期分娩正常孕妇,于妊娠期产前超声多普勒分别检测子宫动脉和脐动脉的搏动指数(PI),比较各组动脉血流异常及妊娠结局不良发生率。 结果：晚发型FGR孕妇中胎儿宫内窘迫所致急诊剖宫产、早产、新生儿1min Apgar评分评分、转入NICU、子宫动脉血流异常及脐动脉血流异常例数发生率分别为48.5%、39.6%、31.4%、35.5%、31.4%和21.9%,均高于对照组(P <0.05);在晚发型宫内生长受限孕妇中妊娠结局不良发生率,D组(子宫动脉和脐动脉血流均异常)明显高于A组(子宫动脉和脐动脉血流均正常),而除了胎儿宫内窘迫所致急诊剖宫产外,B组(子宫动脉异常,脐动脉正常)妊娠结局不良发生率高于C组(子宫动脉正常,脐动脉异常)。 结论：超声多普勒检测检测晚发型胎儿生长受限孕妇的子宫动脉和脐动脉的血流动力学,是了解围产儿预后的有效监护手段,在晚发型胎儿生长受限孕妇中,子宫动脉和脐动脉均异常,提示妊娠合并症增加和围产儿结局不良。     

脉冲式多普勒测定胎儿C/P值及其与脐动脉低氧血症的相关性研究

研究胎儿大脑中动脉搏动指数(PI_MCA)和脐动脉搏动指数(PI_UA)之比(C/P)与新生儿脐动脉低氧血症的关系,使C/P值应用于临床诊断和预测。应用多普勒超声技术,对52例妊娠晚期妇女进行胎儿MCA和UA血流速度波型检查,将C/P值与选择性剖宫产相应新生儿脐动脉血气分析和围产儿结局比较。结果:正常妊娠胎儿C/P值为2.0,重度妊高征、过期妊娠及重度胎动异常孕妇胎儿C/P值小于1;C/P值的降低与新生儿脐动脉低氧、酸中毒及不良围产儿结局相关。结论:C/P值是估计妊娠晚朗胎儿宫内低氧、预测宫内窘迫的敏感指标。     

彩色多普勒超声检测子宫动脉及脐动脉在预测晚发型胎儿宫内生长受限中的价值

目的应用彩色多普勒超声检测母体子宫动脉和胎儿脐动脉评估晚发型胎儿宫内生长受限的血流动力学,预测不良围产儿结局。方法选取晚发型胎儿宫内生长受限的孕妇169例(病例组)和58例同期分娩正常孕妇(对照组),于产前行彩色多普勒超声分别检测孕妇子宫动脉和胎儿脐动脉的搏动指数,比较两组动脉血流动力学异常及妊娠不良结局发生率。再根据病例组孕妇子宫动脉和胎儿脐动脉血流动力学异常情况,分为子宫动脉和脐动脉均正常(A组,99例);子宫动脉异常,脐动脉正常(B组,28例);子宫动脉正常,脐动脉异常(C组,17例);子宫动脉和脐动脉均异常(D组,25例),比较各亚组子宫动脉和脐动脉血流动力学参数和妊娠结局。结果晚发型胎儿宫内生长受限的孕妇中胎儿宫内窘迫所致急诊剖宫产、早产、新生儿1 min Apgar评分、转入新生儿重症监护病房、子宫动脉血流异常及脐动脉血流异常发生率分别为48.5%、39.6%、31.4%、35.5%、31.4%及21.9%,均高于对照组(均P0.05)。病例组中,A组和D组胎儿宫内窘迫所致急诊剖宫产、早产、新生儿1 min Apgar评分及转入新生儿重症监护病房的发生率分别为28.3%和96.0%、20.2%和92.0%、14.1%和76.0%、17.2%和80.0%(均P0.05);B、C组居A、D组之间,且B组高于C组(P0.05)。结论应用彩色多普勒超声检测晚发型胎儿生长受限孕妇的子宫动脉和胎儿脐动脉的血流动力学是了解围产儿预后的有效监护手段;子宫动脉和脐动脉均异常可提示妊娠合并症增加和围产儿结局不良。     

宫内生长受限胎儿的主动脉峡部多普勒评估和围产结局的关系

目的 探讨宫内生长受限(IUGR)胎儿主动脉峡部(AOI)超声多普勒特点及围产期结局的关系。方法 收入41例IUGR患者,根据围产期结局分为两组:围产结局不良组(21例)和围产结局良好组(20例)。对所有病例进行检查及随访,测量参数主动脉峡部、脐动脉、大脑中动脉及静脉导管的搏动指数(pulsatility index,PI),并进行统计学分析。结果 IUGR胎儿围产期不良结局与增高的AOI-PI显著相关(曲线下面积0.7;95%CI,0.52～0.86;P0.05)。结论 AOI-PI是IUGR胎儿围产期不良结局的独立预测指标,表明AOI的多普勒成像在IUGR胎儿临床监测中的潜在重要作用。     

彩色多普勒超声检测孕晚期胎儿动脉阻力参数在高危妊娠围产儿结局评估中的应用价值

目的探讨彩色多普勒超声检测孕晚期胎儿脐动脉(UA)和大脑中动脉(MCA)阻力参数在高危妊娠围产儿结局评估中的应用价值。方法选取2018年1月—2019年4月行彩色多普勒超声检查并有分娩结局的孕晚期(孕28～42周)孕妇230例作为研究对象,根据有无高危妊娠危险因素将其分为高危妊娠组(130例)和正常妊娠组(100例)两组。比较两组胎儿UA和MCA阻力参数[阻力指数(RI)、搏动指数(PI)、收缩期峰值血流速度与舒张末期血流速度比值(S/D)]及围产儿结局指标(出生孕周、新生儿体质量、出生1 min时Apgar评分≤7分和UA pH≤7.20)。结果高危妊娠组胎儿UA阻力参数RI、PI、S/D均高于正常妊娠组,胎儿MCA阻力参数RI、PI、S/D均低于正常妊娠组,差异有统计学意义(P0.05或P0.01)。高危妊娠组围产儿出生孕周小于正常妊娠组,出生体质量低于正常妊娠组,出生1 min Apgar评分≤7分和UA pH≤7.20所占比例高于正常妊娠组,差异均有统计学意义(P0.05或P0.01)。结论高危妊娠孕妇孕晚期彩色多普勒超声检测胎儿UA和MCA阻力参数RI、PI、S/D异常,且其围产儿早产、低体质量和窒息率高,不良妊娠结局增加。彩色多普勒超声检测孕晚期胎儿UA和MCA阻力参数RI、PI、S/D在高危妊娠围产儿结局评估中有重要应用价值。     

晚孕期缺氧高危妊娠胎儿静脉血流波形与不良出生结局的相关性研究

目的 探讨晚孕期缺氧高危妊娠胎儿静脉导管、下腔静脉及肝右静脉血流参数与胎儿异常结局的关系,寻找可以预测高危妊娠胎儿异常结局的静脉血流参数,并比较各血流参数的预测效果.方法 运用彩色多普勒超声检测67例晚孕期缺氧高危胎儿的静脉导管、下腔静脉及肝右静脉血流参数,并对各参数与胎儿的出生结局进行分析研究.结果 晚孕期缺氧高危妊娠胎儿的异常结局可由肝右静脉搏动指数(RHV-PI)、静脉导管前负荷指数(DV-PLI)、静脉导管S/A比值(DV-S/A)及下腔静脉峰值流速指数(IVC-PVI)这几个血流参数单独进行预测.三条血管的指数中以RHV-PI的预测效果最好,取阳性截断值为2.89时,其预测晚孕期高危胎儿发生异常结局的敏感性为75.0%,特异性为76.7%,正确指数(约登指数)为0.52.结论 在静脉导管、下腔静脉、肝右静脉的众多血流参数中,RHV-PI预测晚孕期高危妊娠胎儿异常结局效果最好,真实性最高,可为.临床及时采取处理措施提供诊断依据.     

彩色多普勒超声在检测脐-胎盘循环状况中的应用

应用彩色多普勒超声血流显像系统检测胎儿脐动脉、大脑中动脉及孕妇子宫螺旋动脉等主要血管的血循环变化,通过测量其收缩期峰值流速与舒张期流速比值、阻力指数、搏动指数3项参数,能较好地反映胎盘循环的病理生理变化.脐动脉血流多普勒测值参数收缩期峰值流速与舒张期流速比值、阻力指数、搏动指数与孕周呈高度负相关:胎儿大脑中动脉血流各检测值均随孕龄增长而呈下降趋势:妊娠后孕妇子宫螺旋动脉的阻力指数、搏动指数低于妊娠前.多项指标联合运用可提高对围产儿不良结局预测的准确性与可靠性.     

彩色多普勒超声测定胎儿MCA、UA及孕妇UtA血流参数预测胎儿宫内窘迫的价值研究

目的:分析运用彩色多普勒超声测定胎儿MCA、UA孕妇UtA血流参数预测胎儿宫内窘迫的临床价值。方法:选取我院2016年3月~2016年12月妇产科收治的产前行彩色多普勒超声检查的脐动脉(UA)异常孕妇50例,测定并记录胎儿大脑中动脉(MCA)、孕妇子宫动脉(UtA)血流参数;分娩时胎儿宫内窘迫25例,正常分娩25例。将前者定为观察组,后者则为对照组。比较两组MCA、UtA血流参数值、及预测宫内窘迫的特异度和灵敏度。结果:观察组UtA的血流参数明显高于对照组(P0.05),差异具有统计学意义。MCA搏动指数(PI),观察组(1.23±0.33)低于对照组(1.40±0.26),差异具有统计学意义(P0.05);脐动脉阻力指数(RI)和胎儿脐动脉收缩压与舒张压的比值(S/D)比较,无统计学意义(P0.05)。两组MCA/UtA比较,观察组高于对照组(P0.05),差异具有统计学意义。MCA/UtA的预测特异度和灵敏度分别为93.11%和67.18%。结论:彩色多普勒超声测定胎儿MCA、UtA血流参数用于预测胎儿宫内窘迫,价值尤为突出。可提前预测胎儿宫内缺氧状况,对诊断胎儿宫内窘迫、降低新生儿死亡率及预防生产风险的发生都有显著意义。     

妊娠期肝内胆汁淤积症的脐动脉超声多普勒变化

目的评价彩色多普勒血流成像检测妊娠期肝内胆汁淤积症(ICP)胎儿血流动力学变化在预测围产儿预后中的价值。方法应用彩超检测119例孕36～40周ICP孕妇及544例同孕周正常孕妇的胎儿脐动脉超声多普勒变化,测出脐动脉血流收缩期峰值(S)与舒张期末流速(D)的比值(S/D)、搏动指数(PI)和阻力指数(RI)值,两者进行比较。结果单纯ICP组与正常妊娠组比较,S/D、PI和RI无统计学差异,而ICP并发胎儿宫内窘迫时与正常组比较,S/D有差异,PI和RI无差异;ICP脐动脉多普勒检查阻力升高者出现胎儿窘迫的敏感性为42.9%,特异性为89.4%,阳性预测值47.4%。结论彩色多普勒超声监测ICP胎儿脐动脉多普勒测定为临床早期诊断胎儿窘迫提供可靠依据。     

Relationship between arterial and venous Doppler and perinatal outcome in fetal growth restriction.

OBJECTIVE: The aim of this investigation was to assess the relationship between abnormal arterial and venous Doppler findings and perinatal outcome in fetuses with intrauterine growth restriction (IUGR). METHODS: Doppler velocimetry of the umbilical artery (UA), middle cerebral artery (MCA), inferior vena cava (IVC), ductus venosus (DV) and free umbilical vein was performed in 121 IUGR fetuses with a UA pulsatility index (PI) > 2 SD above the gestational age mean and subsequent birth weight < 10th centile for gestational age. Groups based on the last Doppler exam were: 1 = abnormal UA-PI only (n = 42, 34.7%), 2 = MCA-PI > 2 SD below the gestational age mean (= 'brain sparing') in addition to abnormal UA-PI (n = 29, 24.0%), 3 = DV or IVC peak velocity index (PVIV) > 2 SD above the gestational age mean and/or pulsatile UV flow (n = 50, 41.3%). Z-scores (delta indices) were calculated for Doppler indices. Perinatal mortality, respiratory distress (RDS), bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), necrotizing enterocolitis (NEC), circulatory failure and umbilical artery blood gases were recorded. RESULTS: Absence or reversal of umbilical artery end-diastolic flow was observed in 4 (9.5%) of fetuses in group 1, 10 (34.5%) fetuses in group 2 and 41 (82%) fetuses in group 3. A low middle cerebral artery pulsatility index was found in 39 (78%) fetuses in group 3. Multiple regression analysis with gestational age at delivery, delta indices and cord artery blood gas as independent parameters and individual perinatal outcomes as dependent variables was performed. In this analysis the association was strongest with gestational age for each complication. There were no significant differences in Apgar scores between groups. At delivery, 'brain sparing' was associated with hypoxemia and abnormal venous flows with acidemia. Perinatal mortality was highest in group 3 and stillbirth was only observed when venous flow was abnormal. All postpartum complications were more frequent in fetuses with abnormal venous flows. The only statistically significant relation between Doppler indices and outcome was the association between abnormal ductus venosus flow and fetal death (r2 = 0.24, P < 0.05). CONCLUSION: Growth restricted fetuses with abnormal venous flow have worse perinatal outcome compared to those where flow abnormality is confined to the umbilical or middle cerebral artery. In fetuses with low middle cerebral artery pulsatility, venous Doppler allows detection of further deterioration. While abnormal venous flows can be significantly associated with fetal demise, gestational age at delivery significantly impacts on all short-term outcomes.     

Second-trimester ductus venosus measurement and adverse perinatal outcome in fetuses with congenital heart disease.

OBJECTIVE: The purpose of this study was to determine whether Doppler velocimetry of the ductus venosus (DV) predicts adverse perinatal outcome in congenital heart disease (CHD). METHODS: We conducted a retrospective cohort study of all pregnant women undergoing fetal echocardiography for CHD in a single perinatal center during a 2-year period. We compared outcomes for fetuses having a diagnosis of CHD in the second trimester and abnormal DV Doppler velocimetric findings with those having CHD and normal DV Doppler findings. Karyotype, gestational age at delivery, fetal loss rate, and rate of termination were assessed. The referral value for an abnormal DV pulsatility index was above the 95th percentile for gestational age. Statistical analysis included the t test, Fisher exact test, and chi(2) test. RESULTS: The incidence of CHD in our population was 7%. There were 98 patients with CHD; of those, 31 had DV measurement. A total of 9 patients had an abnormal DV. Three of this group (33%) had intrauterine fetal death or perinatal death. In patients with CHD and normal DV measurements, 83% had living children versus 33% in the group with an abnormal DV (P < .05). There was no statistically significant difference in the rate of aneuploidy between the normal DV (15%) and abnormal DV (20%) groups (P = .65). The mean gestational age at delivery was similar between the normal (37.63 weeks) and abnormal (38.33 weeks) DV groups (P = .71). There was no difference in the rate of pregnancy termination. CONCLUSIONS: Abnormal second-trimester DV measurements are predictive of adverse perinatal outcome in patients with CHD, independent of karyotype or gestational age at delivery. This information may have a role in the counseling of parents with CHD.     

Uterine artery score and perinatal outcome.

OBJECTIVE: To evaluate a modified uterine artery score based on the pulsatility index and presence or absence of notching in the Doppler velocity waveform recorded from both uterine arteries in relation to the perinatal outcome. METHODS: A retrospective analysis was performed in 741 third-trimester high-risk pregnancies. The uterine artery score was constructed assigning one point to each abnormal parameter-high pulsatility index and presence of notch-thus ranging from 0 (normal findings in both uterine arteries) to 4 (notch and high pulsatility index in both uterine arteries). In a subgroup with lateral placenta (n = 359), two definitions of abnormal pulsatility index were compared. In the uniform uterine artery score, a pulsatility index > 1.20 in both uterine arteries was considered abnormal, disregarding the placental location; in the subgroup with lateral placenta, the high pulsatility index was defined as > 1.00 on the placental side and > 1.40 on the non-placental side. RESULTS: Receiver-operating characteristic curves did not reveal any difference in the diagnostic capacity between the group with a uniform uterine artery score and the subgroup with lateral placenta (P = 0.54). In the total material, the odds ratios and linear regression analysis showed an increased risk for an adverse perinatal outcome with increasing uterine artery score (P < 0.01). At a uterine artery score > 2, there was a significantly increased risk for operative delivery for fetal distress, neonatal intensive care unit admission, 5-min Apgar score < 7, preterm delivery and delivery of a small-for-gestational age fetus. CONCLUSION: In high-risk third-trimester pregnancies, Doppler velocity waveforms of the uterine arteries can be evaluated using the uterine artery score disregarding the placental location. The uterine artery score possesses a high predictive value regarding adverse perinatal outcome.     

Umbilical vein blood volume flow rate and umbilical artery pulsatility as 'venous-arterial index' in the prediction of neonatal compromise.

OBJECTIVE: To assess the diagnostic power of the umbilical venous-arterial index (VAI) for the prediction of poor fetal outcome. SUBJECTS AND METHODS: This was a retrospective, cross-sectional clinical study in which normalized umbilical vein blood volume flow rate (nUV) (mL/min/kg estimated body weight), umbilical artery pulsatility index (UAPI), the newly developed VAI (nUV/UAPI), and the uterine artery resistance index (UTRI) were determined in 85 fetuses once (17-41 gestational weeks) during pregnancy using standard ultrasound Doppler equipment. A risk score based on umbilical blood pH, 1-min Apgar score, birth weight, duration of gestation, type of respiratory support, and referral to the pediatric department was constructed, and fetuses were assigned to a control or a pathological group accordingly. Logistic regression and analysis of fitted receiver-operating characteristics curves were performed to evaluate the diagnostic power of nUV, UAPI, UTRI, and VAI. RESULTS: The incidence of compromised neonates was 17.6%. The area under the receiver-operating characteristics curve was larger for VAI than for UTRI or for UAPI (P < 0.002). At a cut-off value of 100 mL/min/kg, the sensitivity of VAI to predict poor neonatal outcome was 85% with a 15% false-positive rate. CONCLUSION: Determination of the VAI has a greater diagnostic power to predict poor fetal outcome than the pulsatility index in the umbilical artery or the resistance index in the uterine artery.     

Antenatal prediction of intraventricular hemorrhage in fetal growth restriction: what is the role of Doppler?

OBJECTIVE: To evaluate relationships between neonatal intraventricular hemorrhage and altered brain blood flow in preterm growth-restricted fetuses. METHODS: One hundred and thirteen growth-restricted fetuses (birth weight < 10th centile and umbilical artery pulsatility index > two standard deviations above gestational age mean) which delivered prematurely (< 34.0 weeks) were studied. Three expressions of altered brain blood flow were defined: 'brain sparing'= middle cerebral artery pulsatility index > two standard deviations below the gestational age mean, 'centralization' = ratio of middle cerebral artery/umbilical artery pulsatility indices (cerebroplacental ratio) > two standard deviations below the gestational age mean, and 'redistribution' = absent or reversed umbilical artery end-diastolic velocity. Intraventricular hemorrhage was graded after Papile (I-IV) by cranial ultrasound performed within 7 days of delivery. RESULTS: Sixty-seven (59.3%) fetuses had brain sparing, 84 (74.3%) had centralization and 51 (45.1%) had redistribution. Fifteen (13.3%) neonates had intraventricular hemorrhage and were more likely to have a biophysical profile < 6, earlier delivery for fetal indications, lower cord artery pH, HCO3, hemoglobin, and platelets, a 10-min Apgar score < 7 and high perinatal mortality (5/15; 33.3%). No associations between intraventricular hemorrhage and brain sparing or centralization were identified. However, neonates with intraventricular hemorrhage had significantly higher umbilical artery pulsatility index deviations from the gestational age mean and a relative risk of 4.9-fold for intraventricular hemorrhage with redistribution (95% confidence interval, 1.5-16.3; P < 0.005). Multiple logistic regression revealed significant associations between intraventricular hemorrhage and a low 10-min Apgar score (r = 0.30, P < 0.005) and low hemoglobin (r = 0.28), gestational age at delivery (r = 0.25) and birth-weight centiles (r = 0.23) (P < 0.05). No Doppler parameter was identified as an independent contributor to intraventricular hemorrhage. CONCLUSION: While loss of umbilical artery end-diastolic velocity early in gestation significantly increases the risk for neonatal intraventricular hemorrhage, prematurity and difficult transition to extrauterine life remain the most important determinants of intraventricular hemorrhage.     

Umbilical artery velocimetry and non-stress test in monitoring high-risk pregnancies. A comparative longitudinal study.

In a longitudinal comparative study, umbilical artery velocimetry and the non-stress test were used in parallel for surveillance of 153 hospitalized high-risk pregnancies. The occurrence of abnormal flow velocity waveforms of the umbilical artery, with increased pulsatility index but maintained diastolic flow velocity, was an inconsistent finding and often related to pregnancy complications other than intrauterine growth retardation. Among patients with small-for-gestational age fetuses or pre-eclampsia with a small-for-gestational age fetus, there was a significantly higher frequency of abnormal umbilical flow velocity waveforms. This was a consistent finding and was often associated with an absence of diastolic flow velocity and operative delivery for fetal distress. An abnormal non-stress test had a significant relationship with intrauterine growth retardation, but a lower predictive capacity for this condition than the abnormal umbilical artery flow velocity waveform. In patients with small-for-gestational age fetuses and no other complication of pregnancy, umbilical artery velocimetry can be used as a reliable tool for identifying those fetuses that need intensified surveillance. In cases with additional complications, a combined use of blood velocimetry and the non-stress test is advocated.     

Staging of intrauterine growth-restricted fetuses.

OBJECTIVE: The purpose of this study was to evaluate the value of cardiovascular, ultrasonographic, and clinical parameters for developing a staging classification of intrauterine growth-restricted (IUGR) fetuses delivered at 32 weeks or earlier. METHODS: Intrauterine growth restriction was defined as the presence of an estimated fetal weight below the 10th percentile. Intrauterine growth-restricted fetuses were staged according to the following parameters, with the presence of any 1 parameter in a stage placing the fetus in that stage: stage I, an abnormal umbilical artery or middle cerebral artery pulsatility index; stage II, an abnormal middle cerebral artery peak systolic velocity, umbilical artery absent/reversed diastolic flow, umbilical vein pulsation and an abnormal ductus venosus pulsatility index; and stage III, reversed flow at the ductus venosus or reversed flow at the umbilical vein, an abnormal tricuspid E wave (early ventricular filling)/A wave (late ventricular filling) ratio, and tricuspid regurgitation. Each stage was divided into A (amniotic fluid index [AFI] <5 cm) and B (AFI >5 cm). The presence of maternal abnormalities was also reported. RESULTS: Seventy-four IUGR fetuses delivered at 32 weeks or earlier were included. Gestational age at delivery was greater in stage I fetuses compared with the other stages. Birth weight decreased with advancing stages. Stage III fetuses had the lowest AFI. There was a direct correlation between the severity of staging and both perinatal mortality and mortality occurring between 20 weeks' gestation and before the neonates were discharged from the hospital (P < .05). CONCLUSIONS: The staging system proposed here may allow comparison of outcome data for IUGR fetuses and may be valuable in determining more timely delivery for these high-risk fetuses.     

The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens.

OBJECTIVE: To test the hypothesis that hemodynamic changes depicted by Doppler precede deteriorating biophysical profile score in severe intrauterine growth restriction. METHODS: Intrauterine growth-restricted fetuses with elevated umbilical artery Doppler pulsatility index (PI) > 2 standard deviations above mean for gestational age and birth weight < 10th centile for gestational age were examined longitudinally. Fetal well-being was assessed serially with five-component biophysical profile scoring (tone, movement, breathing, amniotic fluid volume and non-stress test) and concurrent Doppler examination of the umbilical artery, middle cerebral artery and ductus venosus, inferior vena cava and free umbilical vein. For fetuses with a final biophysical profile score < 6/10, progression of biophysical profile scoring, arterial PI and venous peak velocity indices were analyzed longitudinally. Gestational age effect was removed by converting indices to Z-scores (deviation from gestational age mean, in standard deviations). RESULTS: Forty-four of 236 intrauterine growth-restricted fetuses (18.6%) required delivery for abnormal biophysical profile scoring. The median gestational age at entry was 25 weeks and 1 day and at delivery was 29 weeks and 6 days. The median interval between examinations was 1.5 days and the majority had daily testing in the week prior to delivery. Between first examination and delivery, significant deterioration was observed for Doppler criteria (chi-square, P < 0.001) and biophysical parameters (Fisher's exact, P = 0.02) predominantly confined to the week prior to delivery/stillbirth. Doppler variables changed first. In 42 fetuses (95.5%), one or more vascular beds deteriorated, accelerating especially in the umbilical artery and ductus venosus at a median of 4 days before biophysical profile scoring deteriorated. Two to 3 days before delivery, fetal breathing movement began to decline. The next day, amniotic fluid volume began to drop. Composite biophysical profile score dropped abruptly on the day of delivery, with loss of fetal movement and tone. Three principal patterns of Doppler deterioration were observed: (i) worsening umbilical artery PI, advent of brain sparing and venous deterioration (n = 32, 72.7%); (ii) abnormal precordial venous flows, advent of brain sparing (n = 6, 13.6%); and (iii) abnormal ductus venosus only (n = 4, 9.1%). In the majority (31, 70.5%), Doppler deterioration was complete 24 h before biophysical profile score decline. In the remainder (11, 25%), Doppler deterioration and biophysical profile score < 6/10 were simultaneous. CONCLUSION: In the majority of severely intrauterine growth-restricted fetuses, sequential deterioration of arterial and venous flows precedes biophysical profile score deterioration. Adding serial Doppler evaluation of the umbilical artery, middle cerebral artery and ductus venosus to intrauterine growth restriction surveillance will enhance the performance of the biophysical score in the detection of fetal compromise and therefore optimizing the timing of intervention.     

Ductus venosus studies in fetuses at high risk for chromosomal or heart abnormalities: relationship with nuchal translucency measurement and fetal outcome.

OBJECTIVE: To investigate, in a high-risk group of fetuses, the role of ductus venosus Doppler velocimetry as a prognostic factor, in addition to nuchal translucency measurement, for predicting chromosomal anomalies and, where the karyotype was normal, for predicting fetal outcome. METHODS: Nuchal translucency was measured and ductus venosus pulsatility index and late diastolic flow (a-wave) were recorded in 186 fetuses at a median gestational age of 12.6 weeks (range, 10-17). Fetal karyotype, the presence of structural anomalies, pregnancy outcome, neonatal examination at birth and postnatal follow up were the outcome values. RESULTS: Nuchal translucency measurement was increased in 112 fetuses. The outcome of pregnancy was normal in 130 fetuses. Fifty-six fetuses had an adverse outcome (46 chromosomal anomalies, three intrauterine deaths, six structural anomalies and one developmental disorder). The sensitivity of an abnormal ductus venosus pulsatility index or of absent or reversed flow during the a-wave was 65% for chromosomal anomalies and 68% for an adverse outcome. The specificity was 79%. There was a significant correlation between nuchal translucency and ductus venosus pulsatility index. In chromosomally normal fetuses with an enlarged nuchal translucency an abnormal ductus venosus flow was associated with a nearly nine-fold increase in adverse outcome (odds ratio 11.7). CONCLUSION: Ductus venosus Doppler velocimetry can be used in addition to nuchal translucency measurement as a predictor of chromosomal anomalies. However, as the ductus venosus blood flow pattern is correlated with nuchal translucency measurement it cannot be used as an independent variable to reduce the indication for fetal karyotyping. Ductus venosus Doppler velocimetry may have a role in the counseling of parents in the case of an enlarged nuchal translucency and normal karyotype by identifying those fetuses in need of an intensive follow up due to an increased risk of adverse outcome.