An investigation of simulated umbilical artery Doppler waveforms. II. A comparison of three Doppler waveform quality indices

Three Doppler waveform quality indices based upon assessment of the noise of the maximum frequency envelope of simulated umbilical artery waveforms were investigated. These indices were: an estimate of the correlation between successive waveforms (QI1), a local linearity measure (QI2) and a ratio of two regions of the Fourier transform amplitude spectrum of the maximum frequency envelope (QI3). Simulated umbilical artery waveforms were acquired from a physiological flow phantom. A test population was used consisting of a large number of waveforms where one of three physical variables had been adjusted to produce waveforms of varying quality. These three physical variables were: beam-vessel angle, beam-vessel axial misalignment and attenuator thickness. For this group of waveforms the accuracy of estimation of the maximum frequency envelope and pulsatility index (PI) were known. All three quality indices gave good separation of high- and low-quality waveforms based upon threshold values of the accuracy of PI and maximum frequency envelope. The dependence of each quality index on fetal breathing, waveform length and waveform pulsatility was investigated. QI2, the local linearity measure, showed most promise in its independence from these variables.     

An investigation of simulated umbilical artery Doppler waveforms. III. The effect of noise reduction algorithms on the maximum frequency envelope and on the pulsatility index.

The effect of two noise reduction algorithms on the accuracy of estimation of the maximum frequency envelope and pulsatility index (PI) of simulated umbilical artery Doppler waveforms was investigated. The algorithms were: first, smoothing of the envelope from unfiltered Doppler spectra using a double window modified trimmed mean (DWMTM) filter and second, speckle and noise reduction of the Doppler spectrum using an image processing method. The test population consisted of waveforms were the degree of beam-vessel misalignment had been varied. The accuracy of estimation of the maximum frequency envelope and the PI was calculated by comparing each set of waveforms with the gold-standard maximum frequency envelope from the ensemble averaged waveform obtained with no misalignment. Speckle reduction gave rise to PI values that were low by approximately 0.1 (3%-4%). When there was no background noise present the improvements in envelope estimation were factors of 1.27 and 1.24, respectively, for the DWMTM method and the spectral filter, whereas the factors were 1.56 and 2.07 when background noise was present. For estimation of PI the DWMTM filter was superior. For no background noise the DWMTM filter gave a factor of 3.36 improvement whereas there was no improvement with the spectral filter. When background noise was present the factors for improvement in PI estimation were 2.39 and 4.16.     

An investigation of simulated umbilical artery Doppler waveforms. I. The effect of three physical parameters on the maximum frequency envelope and on pulsatility index

The effect of three physical parameters on the accuracy of estimation of the maximum frequency envelope and pulsatility index (PI) of simulated umbilical artery Doppler waveforms was investigated. The physical parameters were beam-vessel angle, the offset between the beam axis and vessel axis, and the thickness of overlying attenuating material. Waveforms were acquired using a physiological flow phantom. The maximum frequency envelope was calculated using a threshold maximum frequency follower which was adaptive to the level of background noise. A gold standard maximum frequency envelope was obtained from the ensemble averaged waveform when there was alignment of beam and vessel axis, a 50 degrees beam-vessel angle and 2 cm of attenuating material. Indices of bias, variability and accuracy of estimation of the maximum frequency envelope and PI were calculated by comparing subsequent maximum frequency envelopes with the gold standard maximum frequency envelope. Both the maximum frequency envelope and PI were estimated to a similar degree of accuracy over a wide range of physical conditions. In this study, the error in PI was less than 0.15 for beam-vessel angles less than 80 degrees, for beam-vessel axis offset distances less than 7.5 mm, at a transducer-vessel distance of 5 cm, and for attenuator thicknesses less than 4.5 cm. The percentage root-mean square error for estimation of the maximum frequency envelope was approximately 10% or less for beam-vessel angles less than 75 degrees, for beam-vessel axis offset distances less than 7.5 mm, and for attenuator thicknesses less than 4 cm.     

The choice of index for umbilical artery Doppler waveforms

Umbilical artery Doppler waveforms acquired from 211 patients were used to investigate the power of different waveform indices in predicting antenatal fetal compromise. Waveform indices were calculated using a BBC microcomputer. The specificity at 100% sensitivity for detection of antenatal fetal compromise was not significantly different for resistance index, pulsatility index, normalised resistance index and normalised pulsatility index, and was approximately 80%. For the indices of resistance time and downslope the specificity was significantly lower. This similarity in the power of a number of indices in the detection of antenatal fetal compromise suggests that standardisation to one of the simpler indices such as resistance index or pulsatility index could be adopted.     

The pulmonary vein Doppler flow velocity waveform: feature analysis by comparison of in vivo pressures and flows with those in a computerized fetal physiological model.

OBJECTIVES: Doppler flow velocity waveforms (FVW) in fetal veins that discharge into the atria show fluctuations related to atrial events. Pulmonary veins are of particular interest because both ends (atrial and collecting venule) are within the intrathoracic pressure environment reducing fetal breathing artifacts. Indices, such as pulsatility index for veins (PIV), have been suggested to classify FVWs and relate them to fetal well being. We wished to examine the relationship between function and FVW in circumstances which cannot ethically be examined in vivo, by studying the mechanisms which produced altered 'flows' in a detailed fetal computer model. We then related these findings to current flow indices. METHODS: A computer model of the feto-placental unit, responding to changes in organ oxygenation and regional flow is briefly described. In vivo intracardiac pressures and FVWs obtained from other studies were used to extend detail in the model until matching 'pressures' and 'flows' resulted. The effects of flow redistribution in the hypoxic fetus on pulmonary vein 'Doppler' flow velocity waveforms were then studied. RESULTS AND CONCLUSIONS: Flow reversal in pulmonary veins during atrial contraction indicates hypoxia, but change of shape of the FVW envelope reflects the changes in the pressure waveform of the left atrium. Of the major veins the pulmonary vein Doppler FVW gave the truest representation of atrial pressure response to both intracardiac and systemic vascular status. Although current indices indicate general fetal condition, more specific indices are needed if pulmonary venous flow is to be used as an end-point. A pulmonary vein pressure gradient index is suggested.     

Determination of the presence of fetal apnoea using umbilical artery and umbilical vein Doppler waveforms

Fetal breathing movements were observed using real-time ultrasound imaging. Simultaneous Doppler recordings of the flow velocity waveform from the umbilical artery and umbilical vein were obtained. Twenty patients were studied. The Doppler traces obtained during fetal apnoea and fetal breathing for each patient were analysed using a BBC microcomputer. A combination of venous variation index (VVI) and the coefficient of variation of arterial pulsatility index (CVPI) gave complete separation between breathing and apnoeic groups (lower values of VVI and CVPI being associated with the apnoeic group). Hence, when stand alone continuous wave Doppler units are used to acquire umbilical artery Doppler waveforms during fetal apnoea, the presence of apnoea can be determined using the variability of the arterial and venous trace without the need for visualisation of the fetus using imaging equipment.     

Comparison of umbilical artery flow velocity waveform indices as measured by continuous wave Doppler ultrasound

This study examines four methods, automated and manual, of calculating the pulsatility index (PI) of fetal umbilical artery flow velocity waveforms (FVW) and compares these values to the resistance index (RI), the A/B ratio, and the degree of absence of end diastolic frequencies. The FVWs were obtained by the Doptek continuous wave Doppler ultrasound. All of the maximum envelope indices had significant correlations; a highly significant difference was found between the automated and the manual methods of determining PI. When PI was measured manually, there was a better correlation between the A/B ratio, RI, and degree of absence of end diastolic frequencies than when the automated methods were used.     

A comparison of Doppler ultrasound waveform indices in the umbilical artery--II. Indices derived from the mean velocity and first moment waveforms

Umbilical artery Doppler recordings in both normal pregnancy and cases of fetal growth failure were processed by computer. Representative waveforms for the maximum velocity, mean velocity and first moment were obtained after ensemble averaging and correction for thump filtering. The same set of indices, which included the AB ratio, pulsatility index, rising slope and relative flow rate index, were calculated for each of the waveforms. The results were compared to identify differences which might arise in clinical practice if a waveform other than the usual (maximum velocity) was used. The ratio of the mean to the maximum velocity, which gives an indication of the velocity profile, was shown to be very error prone. The reproducibility of the mean velocity and first moment indices was inferior to that of the maximum velocity indices. The results from the different waveforms were highly correlated for normals for most indices. However, in the growth retarded group there was a tendency for the mean velocity and first moment indices to classify as normal studies classified as abnormal by the maximum velocity index. The values of indices derived from the first moment waveform were generally larger than the maximum and mean velocity values. For the relative flow rate index, where results were often different to the general trend, the values were more nearly equal.     

Intraobserver variation in Doppler ultrasound indices of placental perfusion derived from different numbers of waveforms.

Continuous-wave ultrasound is used to obtain records of Doppler-shifted frequencies from arteries. Indices using the maximum frequency envelope are usually derived from a number of selected waveforms on each record and averaged. Analysis of variance was performed on indices obtained from repeated Doppler ultrasound waveform records of uterine and umbilical perfusion in late pregnancy. Intraobserver variation was minimal when derived from six (consecutive) waveforms and was less than 10% for each index.     

First-trimester uteroplacental and fetal blood flow velocity waveforms in normally developing fetuses: a longitudinal study.

Our objectives were to obtain a complete overview of uteroplacental and fetal hemodynamics early in pregnancy and to record flow velocity waveforms in the vitelline artery using color Doppler equipment. Flow velocity waveforms were recorded in 18 uneventful pregnancies between 6 and 16 weeks of gestation. Doppler recordings were made of the left and right uterine and spiral arteries from 6 weeks of gestation onwards. Recordings of c the umbilical artery, fetal aorta and fetal cerebral arteries started in weeks 7, 8 and 9, respectively. Where possible, the vitelline arteries were also recorded. The resistance and pulsatility indices and 95% confidence intervals for predictions were calculated.For the uterine and spiral arteries, characteristics of the waveforms were assessed. The resistance index of both uterine and spiral arteries gradually decreased with advancing pregnancy. For the umbilical artery, aorta and cerebral artery, the earliest possible Doppler recordings and characteristics of the waveforms were established. The pulsatility index of the umbilical arteries and fetal aorta showed a sharp decrease towards the 16th week. The pulsatility index of the fetal cerebral artery showed only a mild decrease towards week 16. In a longitudinal analysis, there were significant changes of the resistance and pulsatility indices for each patient. In the vitelline artery, recordings were possible in eight out of 18 fetuses, and only in weeks 7 and 8 of gestation. The pulsatility index showed a wide range and was not dependent on menstrual age.Knowledge of the normal flow velocity waveforms in the maternal uteroplacental and fetal circulations early in pregnancy may lead to a better understanding of physiological mechanisms.     

A comparison of Doppler ultrasound waveform indices in the umbilical artery--I. Indices derived from the maximum velocity waveform

Various Doppler waveform indices have been used for assessment of the fetal circulation. Comparisons were made to show what relations exist between the indices, and to identify any differences or difficulties which might arise from using one as opposed to another in clinical practice. Both normal pregnancy and cases of fetal growth failure were studied. Indices were obtained from the maximum velocity envelope of the umbilical artery waveform using a curve fitting technique. The values were very reproducible for all indices. The FHR, which varied over the entire normal range, did not significantly affect the values of any index. The downstream impedance indices calculated included the AB ratio, pulsatility index (PI) and Pourcelot ratio. These all gave very closely correlated results for normals but discrepancies occurred in the at risk group, where values were elevated. This could be attributed to differences in the underlying distributions. The indices suggested for cardiac contractility were not as closely related to each other, and moreover the differences between them showed no clear pattern. None of the indices varied independently of the others. The rising slope, which is by definition related to the PI, was more highly correlated with the downstream indices than the relative flow rate index.     

Algorithms to qualify respiratory data collected during the transport of trauma patients

We developed a quality indexing system to numerically qualify respiratory data collected by vital-sign monitors in order to support reliable post-hoc mining of respiratory data. Each monitor-provided (reference) respiratory rate (RR(R)) is evaluated, second-by-second, to quantify the reliability of the rate with a quality index (QI(R)). The quality index is calculated from: (1) a breath identification algorithm that identifies breaths of 'typical' sizes and recalculates the respiratory rate (RR(C)); (2) an evaluation of the respiratory waveform quality (QI(W)) by assessing waveform ambiguities as they impact the calculation of respiratory rates and (3) decision rules that assign a QI(R) based on RR(R), RR(C) and QI(W). RR(C), QI(W) and QI(R) were compared to rates and quality indices independently determined by human experts, with the human measures used as the 'gold standard', for 163 randomly chosen 15 s respiratory waveform samples from our database. The RR(C) more closely matches the rates determined by human evaluation of the waveforms than does the RR(R) (difference of 3.2 +/- 4.6 breaths min(-1) versus 14.3 +/- 19.3 breaths min(-1), mean +/- STD, p < 0.05). Higher QI(W) is found to be associated with smaller differences between calculated and human-evaluated rates (average differences of 1.7 and 8.1 breaths min(-1) for the best and worst QI(W), respectively). Establishment of QI(W) and QI(R), which ranges from 0 for the worst-quality data to 3 for the best, provides a succinct quantitative measure that allows for automatic and systematic selection of respiratory waveforms and rates based on their data quality.     

Fetal cerebral blood flow velocity during labor and the early neonatal period.

This study was performed to elucidate circulatory changes in the fetal cerebral circulation during uncomplicated labor and in early neonatal life. Eighteen healthy term singleton fetuses were followed longitudinally during labor. Using the transabdominal approach, and the color Doppler technique, the middle cerebral artery was identified and Doppler flow velocity waveforms recorded between and during uterine contractions. Neonatal recordings were made by insonating the middle cerebral artery from the temporal region before and immediately after the cutting of the umbilical cord, and at 1 hour and 1 day after birth. The recorded Doppler signals were evaluated for pulsatility index, heart rate, peak systolic flow velocity, end-diastolic flow velocity and time-averaged maximum velocity. There was no change in the pulsatility index between and during contractions (1.39 +/- 0.36 and 1.40 +/- 0.39, respectively, mean +/- SD). A significant decrease in the pulsatility index compared to fetal values was seen 4 min after birth (1.06 +/- 0.30, p < 0.01). One hour after birth, the pulsatility index values increased significantly (1.52 +/- 0.25, p < 0.001), to fall again between I hour and 1 day after birth (0.95 +/- 0.26, p < 0.001). Mechanical compression of the skull, blood gas changes and a decrease in ductal shunting may all have contributed to these changes. The present study has shown physiological neonatal circulatory adaptation and onset of breathing to cause manifest changes in cerebral blood flow velocity.     

Color Doppler sonographic assessment of placental circulation in the first trimester of normal pregnancy.

Our aim was to study placental circulation during the first trimester of normal pregnancy. For this purpose, 108 single pregnancies from 4 to 15 gestational weeks were evaluated through conventional Doppler ultrasonography. The flow velocity waveforms from the retrochorionic arteries (spiral-radial arteries) and the umbilical artery were assessed using the peak systolic velocity, resistive index, and pulsatility index). Intervillous flow velocity waveform was evaluated from the maximum velocity. The earliest color signal from the retrochorionic circulation was registered at 4.5 weeks along with gestational sac visualization. The venous Doppler signal from the intervillous space and the Doppler signal from the umbilical artery were recorded with an embryo visible from the end of week 5 onward. The retrochorionic, intervillous, and umbilical peak systolic velocities increase, whereas the resistive and pulsatility indices decrease progressively during early pregnancy with a significant correlation with gestational age. Similarly, intervillous maximum velocity gradually increases throughout the first trimester of pregnancy. Despite some methodologic problems related to Doppler technology and the vessels studied color Doppler sonography appears to be an adequate tool to assess the physiologic changes in the placental circulation during early pregnancy.     

Changes in fetal hemodynamics with ritodrine tocolysis.

OBJECTIVE: To evaluate the effect of ritodrine on the fetal cardiovascular system. METHODS: Cardiac and extracardiac Doppler waveforms were recorded in 12 fetuses prior to and during ritodrine therapy used for preterm labor. Maternal and fetal heart rates, the Doppler pulsatility indices of the umbilical artery, middle cerebral artery, descending thoracic aorta and renal artery, and time velocity integrals of the atrioventricular valves and the ductus arteriosus, were measured. RESULTS: Ritodrine infusion caused an increase in maternal and fetal heart rates, the left cardiac output as measured by the product of time velocity integral and heart rate, and the pulsatility index of the middle cerebral artery, and a decrease in the pulsatility index of the umbilical artery. CONCLUSIONS: Ritodrine infusion may alter placental and cerebral blood flow and may have a selective effect on the left side of the heart.     

Do ultrasonic contrast agents artificially increase maximum Doppler shift? In vivo study of human common carotid arteries.

The aim of this study was to establish whether an increase of maximum Doppler shift occurs in the human common carotid artery after the administration of Levovist, an ultrasonographic echo enhancer. Twenty common carotid arteries of 10 patients were examined. Spectral Doppler waveform examinations were performed before and after administration of Levovist using an Acuson 128 XP 10 and a 7.0 MHz transducer probe. Time averaged mean velocity, peak velocity, maximum Doppler shift, and spectral Doppler indices (pulsatility index, resistive index, systolic-diastolic ratio) were assessed. No significant changes in any of the measured parameters, including maximum Doppler shifts, peak velocity (P = 0.35, Wilcoxon rank sum test), pulsatility indices (P = 0.70), resistive indices (P = 0.98), or other spectral indices, were found. We conclude that an increase in Doppler shift does not inevitably occur after the administration of a signal enhancer when examining the human common carotid artery.     

Fetal peripheral bronchial fluid flow during breathing movement in normal pregnancies: a preliminary study.

OBJECTIVE: To determine the fluid flow velocity waveforms in the fetal peripheral bronchus during fetal breathing movement by means of pulsed Doppler ultrasonography. DESIGN: A preliminary cross-sectional study. SUBJECTS: Twenty-eight normal pregnant women between 32 and 38 weeks of gestation. METHODS: Velocity waveforms from fetal peripheral respiratory fluid flow were acquired from the segmental bronchus (B6 or B8) which runs along the segmental artery (A6 or A8). The maximum velocity of the intrabronchial fluid flow and duration of inspiratory and expiratory phases were quantified. RESULTS: The flow velocity signal from the fluid in the fetal segmental bronchus of 17 of the 28 fetuses was detected. We observed two types of fetal breathing movement. CONCLUSION: During fetal breathing movement, the fluid in the fetal respiratory tract moves in the fetal segmental bronchus. This movement can be detected by pulsed Doppler velocimetry aided by power Doppler ultrasonography.     

Longitudinal changes in the ductus venosus, cerebral transverse sinus and cardiotocogram in fetal growth restriction.

OBJECTIVE: To evaluate the changes in flow velocity waveforms in the transverse cerebral sinus in growth-restricted fetuses and to correlate these changes with (1) flow velocity waveforms in the ductus venosus and (2) changes in computerized analysis of the fetal cardiotocogram. DESIGN: Fetuses between 22 and 37 weeks' gestation with an estimated fetal weight below the fifth centile were included in this prospective longitudinal study. Doppler measurements of the umbilical artery, descending aorta, middle cerebral artery, transverse cerebral sinus and ductus venosus were recorded. Fetal heart rate was analyzed by a computer system according to the Dawes-Redman criteria. RESULTS: We measured a significant correlation between pulsatility index in the cerebral transverse sinus and in the ductus venosus over the study period and at delivery. There was a negative correlation between these indices and short- and long-term variability of the fetal heart rate. There was a parallel increase in pulsatility in the ductus venosus and the transverse cerebral sinus. These changes were inversely correlated with fetal heart rate variability and preceded fetal distress. CONCLUSION: Cerebral venous blood flow in IUGR fetuses may be a useful additional investigation to discriminate between fetal adaptation and fetal decompensation in chronic hypoxemia.     

Influence of fetal breathing and movements on variability of umbilical Doppler indices using different numbers of waveforms

Umbilical artery continuous-wave Doppler ultrasound waveforms were obtained from three groups of fetuses in late gestation: during quiescence, fetal breathing movements, and fetal body movements. The coefficients of variation, calculated from three values for each Doppler index, which were derived from one, two, four, six and eight waveforms, decreased as the number of waveforms increased. However, statistical analysis showed no significant improvement in variance when more than four waveforms were used during fetal quiescence and breathing and when more than six waveforms were used during fetal movement. A minimum of six waveforms ensured coefficients of variation less than or equal to 10% even during fetal breathing and fetal movements.     

Waveform pattern recognition--a new semiquantitative method for analysis of fetal aortic and umbilical artery blood flow velocity recorded by Doppler ultrasound

A semiquantitative computerized waveform pattern recognition system for analysis of the fetal descending aortic and umbilical artery Doppler flow velocity waveforms is presented. Based on empirically and manually selected clinical recordings from both vessels, 11 computerized and normalized standard curves for the aorta (type curves A to K), and 10 curves for the umbilical artery (type curves a to j) were constructed. The best match between the normalized waveform and the standard curve was based on either the degree of absent diastolic flow or, in cases with positive diastolic flow, on the calculation of the least square sum of the difference. The pattern recognition was tested against conventional waveform indices and our older semiquantitative Blood Flow Class (BFC) system in 472 clinical consecutive Doppler recordings. A good correlation was found. This new relatively simple computer-based method for waveform analysis is now prospectively applied in clinical studies.