Use of peak systolic velocity in the middle cerebral artery after serial intravenous fetal exchange transfusions in the end of pregnancy

Objectives

Our aim was to assess the efficiency of the peak systolic velocity in the middle cerebral artery (PSV-MCA) to predict neonatal anemia at the end of pregnancies after serial intravenous fetal exchange transfusions (IFET) for red-cell fetomaternal immunization.

Patients and methods

We conducted a retrospective study from 01/01/2004 to 31/12/2009 of 25 pregnancies after IFET for red-cell fetomaternal immunization, in Saint Vincent de Paul Hospital, Paris. The study assessed correlation between the last prenatal PSV-MCA measured and hemoglobin concentration at birth and other neonatal data.

Results

Last prenatal PSV-MCA and hemoglobin concentration at birth were significantly correlated (r = −0.39, P < 0.01).

Conclusion

There is a good correlation between last PSV-MCA measured before birth and neonatal haemoglobin and complexity of neonatal care linked to anemia. Cerebral Doppler is useful for the follow-up of pregnancies at risk for anemia even in the end of the pregnancy and after serial intravenous fetal exchange transfusions.     

The effect of fetal behavioral states on middle cerebral artery peak systolic velocity

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: Healthy preterm fetuses have a significantly higher MCA PSV during the active state. Activity state should be considered when interpreting MCA Doppler indices.     

Correction of fetal anemia on the middle cerebral artery peak systolic velocity

OBJECTIVE: To assess the effect of correction of fetal anemia on the middle cerebral artery peak systolic velocity values. METHODS: With Doppler ultrasonography, middle cerebral artery peak systolic velocity was measured in 41 fetuses before and immediately after 54 intrauterine transfusions for severe red blood cell alloimmunization. The fetuses were divided into two groups: 17 fetuses studied at first transfusion (group A), and 24 fetuses enrolled to the study after the first transfusion (group B). Both fetal hemoglobin and middle cerebral artery peak systolic velocity were plotted over the respective reference ranges as a function of gestational age. Both values were expressed as multiples of the median and analyzed with paired t test. RESULTS: The values of middle cerebral artery peak systolic velocity decreased in all but one fetus of group B (P <.05). The values of middle cerebral artery peak systolic velocity before transfusion were above the upper limit of the reference range in 60% of the fetuses of group A and in 38% of group B, respectively. After correction of anemia, only one value remained above the upper limit of the reference range. CONCLUSION: The correction of fetal anemia with intrauterine blood transfusion decreases significantly and normalizes the value of the fetal middle cerebral artery peak systolic velocity.     

Ultrasound assessment of the fetal middle cerebral artery peak systolic velocity: A comparison of the near-field versus far-field vessel

OBJECTIVE: Doppler assessment of the fetal middle cerebral artery peak systolic velocity may obviate the need for more invasive procedures in the alloimmunized patient. The purpose of this study was to compare middle cerebral artery peak systolic velocity measurements in the near field and far field. STUDY DESIGN: Patients between 16 and 42 weeks of gestation with normal fetuses were eligible (n=151). Peak systolic velocity measurements were obtained at the proximal portion of each middle cerebral artery at its origin in the internal carotid artery, as well as the most distal portion before its division, for a total of 4 measurements per fetus. Comparisons were made among the 4 locations and the data were analyzed using a mixed-model analysis of variance adjusted for gestational age. Results were presented using both P values and 95% CIs. P values <.05 were considered statistically significant. Where appropriate, P values and 95% CIs were adjusted using the Tukey multiple comparison procedure. A subanalysis was performed using 11 patients to assess interobserver reliability, which was calculated using the intraclass correlation coefficient (ICC). RESULTS: All four measurements were obtained for 120 fetuses (79%). The mean gestational age was 27.0 weeks. Statistically significant differences were noted between distal sites (95% CI, -0.05 to 0.01; P<.01) as well as the two sites on each vessel (95% CI, 0.03-0.07 and 0.07-0.12; P<.001 for both vessels). There was no significant difference between the two proximal locations (95% CI, -0.01 to 0.03; P=0.77). CONCLUSION: By which of the 2 vessels the fetal middle cerebral artery peak systolic velocity is affected is selected, as well as the location on the vessel. If the near-field proximal site cannot be interrogated, the far-field proximal site may be the best alternative.     

The value of middle cerebral artery peak systolic velocity in the diagnosis of fetal anemia after intrauterine death of one monochorionic twin

OBJECTIVE: The purpose of this study was to assess the value of the fetal middle cerebral artery peak systolic velocity in the prediction of anemia within 24 hours of the death of one monochorionic twin in twin-to-twin-transfusion syndrome and to establish the correlation between middle cerebral artery peak systolic velocity and hemoglobin concentration in fetuses who are at risk for acute anemia. STUDY DESIGN: Doppler examination of the middle cerebral artery peak systolic velocity was performed in 20 monochorionic survivors of pregnancies that were complicated by twin-to-twin-transfusion syndrome that occurred between 20 and 34 weeks of gestation. Doppler examination was performed before cordocentesis and after intrauterine transfusion when appropriate. Both hemoglobin concentration and middle cerebral artery peak systolic velocity were expressed in multiples of the median. Severe anemia was defined as hemoglobin concentration of <0.55 multiples of the median, and we used the cutoff point of 1.50 times the median values at any gestational age to calculate the sensitivity and specificity of middle cerebral artery peak systolic velocity in detecting moderate or severe anemia. RESULTS: Fetal anemia was confirmed in 10 of 20 fetuses. We performed seven intrauterine transfusions. The sensitivity and specificity of middle cerebral artery peak systolic velocity in the prediction of severe fetal anemia were of 90%, with a false-negative rate of 10%. The correlation between peak systolic velocity and hemoglobin concentration both before and after transfusion was evaluated by regression analysis and was strongly significant. CONCLUSION: In fetuses who are at risk of acute anemia, the measurement of middle cerebral artery peak systolic velocity was found to be a reliable noninvasive diagnostic tool and may be helpful in counseling and planning invasive assessment.     

胎儿大脑中动脉收缩峰期血流速度与二维超声预测重型α地中海贫血的对比研究

目的:探讨和比较应用超声多普勒技术测量胎儿大脑中动脉收缩峰期血流速度(MCA-PSV)与二维超声预测胎儿重型α地中海贫血(地贫)的价值。方法:为129例具有重型α地贫风险的胎儿行二维及多普勒超声检查,测量胎儿MCA-PSV并行羊膜腔穿刺或脐血穿刺术进行α地贫基因诊断。MCA-PSV用中位数的倍数(MOM)表示。结果:重型α地贫胎儿MCA-PSV明显高于非重型α地贫胎儿,差异有显著的统计学意义(P0.001)。MCA-PSV1.29MOM预测胎儿重型α地贫的检出率为81.25%,高于二维超声(P0.05);MCA-PSV联合二维超声对胎儿重型α地贫的检出率为90.63%。MCA-PSV最早可在孕16周预测胎儿重型α地贫,MCA-PSV预测胎儿重型α地贫的平均孕龄小于二维超声(P0.05)。结论:MCA-PSV预测胎儿重型α地贫优于二维超声。MCA-PSV联合二维超声可提高胎儿重型α地贫的检出率。超声多普勒测量胎儿MCA-PSV对早期预测胎儿重型α地贫,早期处理以减少产科并发症的发生具有临床价值。     

Prenatal management of placental chorioangioma: value of the middle cerebral artery peak systolic velocity

Placental chorioangiomas are benign tumors of the placenta. Large chorioangiomas may cause severe complications such as fetal anemia, hydrops and fetal death. We report the use of sonographic findings and peak systolic velocity in the middle cerebral artery in the diagnosis and management of fetal anemia without the occurrence of hydrops fetalis in a pregnant woman with a large placental chorioangioma. Successful intrauterine blood transfusion was performed at 26 weeks. Spontaneous thrombosis of the main supplying blood vessel of the chorioangioma was detected at 33 weeks. The child was delivered at 39 weeks of pregnancy in normal clinical condition.     

Conventional management of maternal red cell alloimmunization compared with management by Doppler assessment of middle cerebral artery peak systolic velocity

OBJECTIVE: This study was undertaken to compare management of red blood cell alloimmunization by Doppler measurement of middle cerebral artery peak systolic velocity (MCA-PSV) to conventional management with amniocentesis. STUDY DESIGN: A historical cohort of 28 fetuses at risk for anemia caused by red blood cell alloimmunization was followed between 1999 and 2002 at a single institution. The decision to perform percutaneous umbilical cord blood sampling (PUBS) was based on conventional management. MCA-PSV Doppler was measured before amniocentesis or PUBS but not used clinically. RESULTS: Twenty-eight fetuses were followed up: 4 had severe anemia, 1 had moderate anemia, 3 had mild anemia, and 20 were nonanemic. Conventional management had a sensitivity and positive predictive value for moderate-to-severe anemia of 80% and 44%, with a false-positive rate of 56%. In the same patients, MCA-PSV Doppler had a sensitivity and positive predictive value for moderate-to-severe anemia of 100% and 71%, with a false-positive rate of 28%. CONCLUSION: Compared with conventional management, MCA-PSV Doppler may have a better predictive accuracy for moderate-to-severe fetal anemia in red blood cell alloimmunization. Management by MCA-PSV Doppler may eliminate the need for amniocentesis and reduce the number of PUBS performed in red blood cell-alloimmunized pregnancies.     

Prediction of fetal anemia by middle cerebral artery peak systolic velocity in pregnancies complicated by rhesus isoimmunization.

OBJECTIVES: To study the correlation of peak systolic velocity in the middle cerebral artery with hemoglobin concentration in fetuses at risk of anemia due to Rhesus isoimmunization. DESIGN: Peak systolic velocity of middle cerebral artery (MCA-PSV) was measured before 66 cordocentesis procedures in 20 isoimmunized fetuses. Reference values were derived from a study of 300 control fetuses. MCA-PSV values and hemoglobin concentrations were expressed as multiples of the median (MoM) for gestational age. The following hemoglobin concentration MoM thresholds defined degrees of anemia: mild, between 0.83 and 0.65; moderate, between 0.64 and 0.55; and severe, less than 0.55. Regression analysis was performed and receiver-operator-characteristic curves were constructed to determine the diagnostic accuracy of different thresholds of MCA-PSV for the prediction of moderate to severe anemia, either at the initial or repeat cordocentesis procedures. RESULTS: The mean (+/-SD) gestational age at cordocentesis was 28.5+/-4.6 weeks. Moderate to severe anemia was observed on 29 (44%) and hydrops on 27 (41%) occasions. MCA-PSV correlated weakly with hemoglobin concentrations. At threshold values 1.50 MoM, the sensitivity, specificity, and negative predictive value for moderate to severe anemia were 9.0, 100, and 48.0% at the initial cordocentesis procedures, and 44.0, 96.0, and 73.0% at repeat cordocentesis procedures, respectively. CONCLUSIONS: Although MCA-PSV is highly specific, negative values do not rule out fetal anemia. Further research is required before it can be recommended in clinical practice.     

The value of middle cerebral artery systolic velocity for initial and subsequent management in fetal anemia.

OBJECTIVE: To evaluate the fetal middle cerebral artery Doppler waveform for the prediciton of anemia in the RhD-alloimmunized fetus. STUDY DESIGN: Doppler velocimetry of the fetal middle cerebral artery peak systolic velocity was measured in 52 non-hydropic, RhD-alloimmunized fetuses who underwent 103 cordocenteses. Normal values were obtained from 70 normal cases. The peak systolic velocity values were expressed as multiples of the median (MoM) for gestation. Hemoglobin threshold for developing hydrops was developed from 22 RhD-alloimmunized hydropic fetuses and severe anemia was defined as Hb< or =0.60 MoM. The most efficient threshold values for the prediction of severe anemia in groups with no prior transfusion and those with prior transfusion were obtained by constructing ROC curves. RESULTS: The mean gestational age (+/-S.D.) at cordocentesis was 28.0 +/- 4.6 weeks. Severe anemia was noted in 53 (51.5%) occasions. At a threshold middle cerebral artery peak systolic velocity value of > or =1.35 MoM, the sensitivity for severe anemia detection was 100% with a false-positive rate of 18%. In sub-analysis, in patients with one or more prior transfusion a sensitivity of 97% and a false-positive rate of 14% obtained at a threshold of > or =1.45 MoM. In patients with no previous transfusion the sensitivity for severe anemia was 100%, with a false-positive rate of 9.1% at a threshold value of > or =1.35 MoM. CONCLUSION: The middle cerebral artery peak systolic velocity can be used to time both the initial diagnostic procedure and retransfusion.     

A comparison between middle cerebral artery peak systolic velocity and amniotic fluid optical density at 450 nm in the prediction of fetal anemia

OBJECTIVE: The purpose of this study was to compare fetal middle cerebral artery peak systolic velocity with amniotic fluid delta optical density at 450 nm in the prediction of fetal anemia. STUDY DESIGN: A prospective study that involved 28 singleton pregnancies that were at-risk for fetal anemia was carried out in a tertiary teaching hospital. Middle cerebral artery peak systolic velocity was measured immediately before the determination of deltaoptical density at 450 nm and fetal hemoglobin concentration. Sensitivities and predictive values for fetal anemia were examined. RESULTS: Fetal hemoglobin concentrations correlated significantly with middle cerebral artery peak systolic velocity (correlation coefficient, -0.77; P <.0001) and deltaoptical density at 450 nm zones (correlation coefficient, -0.56; P =.0025). Middle cerebral artery peak systolic velocity was >1.5 multiples of the median in 15 of 28 cases (54%); for this cutoff value, the sensitivity and positive-predictive values for a hemoglobin deficit of >-3SD were 75% and 60% and for a hemoglobin deficit of >-5SD were 100% and 47%, respectively. The corresponding values for deltaoptical density at 450-nm zone III (6/28 cases, 21%) were 0% (hemoglobin deficit, <-3SD) and 86% and 100% (hemoglobin deficit, <-5SD). CONCLUSION: Middle cerebral artery peak systolic velocity and amniotic fluid optical density at 450 nm are both useful in the prediction of fetal anemia. However, Doppler examination has the advantage of being a noninvasive method that can help reduce the number of invasive procedures in pregnancies that are at-risk for fetal anemia.     

Fetal middle cerebral artery peak systolic velocity as a predictor of fetal anemia in unselected women giving birth at or near term

Objective

This study was performed to evaluate the application of fetal middle cerebral artery peak systolic velocity (MCA-PSV) for prediction of newborn anemia with umbilical cord blood hemoglobin concentration at birth (UCB-Hb) < 10.0 g/dL among infants born at gestational week (GW) ≥ 36 to unselected women.

Longitudinal assessment of the middle cerebral artery peak systolic velocity in healthy fetuses and in fetuses at risk for anemia

OBJECTIVE: Our purpose was to assess the feasibility of longitudinal assessment of the middle cerebral artery peak systolic velocity (MCA-PSV) to predict fetuses who will have severe anemia. STUDY DESIGN: Doppler measurement of MCA-PSV was serially performed in 15 healthy fetuses (99 measurements; range: 4-9 per fetus), 8 fetuses who were mildly anemic (41 measurements; range: 3-10 per fetus), and 11 who were severely anemic (50 measurements; range: 2-7 per fetus) at their first cordocenteses. Linear models were fitted to the data from individual fetuses and the slopes were determined. The average rate of change (slope) of MCA-PSV as a function of gestational age in the 3 groups was calculated from these data. Estimated average slopes were computed using restricted maximum likelihood. F tests were used for hypothesis tests, with the degrees of freedom based on the Kenward and Roger approximation. The values of MCA-PSV and hemoglobin were expressed as multiples of the median (MoM). A P <.05 indicated statistical significance. RESULTS: Gestational age at the time of the Doppler studies ranged from 15.1 to 41 weeks in the healthy fetuses. It was between 15 and 33.4 weeks in the fetuses who became anemic. The estimated average slopes increased with the degree of anemia (P =.03). The difference in mean slope between the severely anemic sample and the healthy sample was statistically significant (estimated difference = 2.2, SE =.65, P =.01). The difference in mean slope between the mildly anemic and healthy samples was not statistically significant (estimated difference = 1.1, SE =.06; P =.08). CONCLUSIONS: We have demonstrated that the MCA-PSV slope is an excellent tool for identifying those fetuses who will become severely anemic and, therefore, need to be followed up more closely during the pregnancy. Our findings expand the clinical applications to which Doppler ultrasonography can be applied in monitoring pregnancies at risk for fetal anemia.