Relationship between doppler velocimetry at middle cerebral artery and umbilical artery and status of newborn after delivery

OBJECTIVES: Aim of research was estimation of correlation between doppler parameters and fetal state after delivery. MATERIAL AND METHODS: One hundred fifty-one pregnancies treated in Dept. of Obstetrics and Gynecology of Medical Academy in Bydgoszcz was investigated between 1998-2002. Pregnancies were estimated between 27 and 43 Hbd. Ultrasound examination using pulse and color Doppler was performed (ACUSON XP 128) and PI, RI, S/D, MCA, UA were estimated. DESIGN: Following doppler parameters were analyzed: pulsatile index (PI), resistance index (RI) and systolic/diastolic ratio (S/D) in middle cerebral artery (MCA) and in umbilical cord artery (UA). The newborn children were estimated by Apgar score in first minute of life (AP1). Correlation between amount of amniotic fluid index (AFI) and newborn state in first minute after delivery was investigated too. RESULTS: There were following correlations in this investigation: (1) negative between UA PI and AP1 (-0.26); (2) negative between UA RI and AP1 (-0.23); (3) negative between UAS/D and AP1 (-0.16); (4) negative between AFI and API (-0.06); (5) lack of statistical correlation between MCA PI, MCA RI, MCA S/D and AP1. We considered following covariancies: (1) negative between AFI and AP1 (-1.03); (2) negative between UA S/D and AP1 (-0.42); (3) negative between UA PI and AP1 (-0.23); (4) negative between UA RI and AP1 (-0.09). CONCLUSIONS: We concluded that Doppler investigations by measure of parameters of blood flow in umbilical cord artery (PI, RI, S/D) can be predictive to fetal threat and useful in estimation of newborn state.     

Relationship between antepartum cocaine abuse, abnormal umbilical artery Doppler velocimetry, and placental abruption

We performed serial umbilical artery Doppler flow velocimetry studies on 314 women and grouped them according to history of antepartum cocaine abuse, placental abruption with antepartum cocaine abuse, preterm labor with antepartum cocaine abuse, preterm labor without antepartum cocaine abuse, and controls without preterm labor or antepartum cocaine abuse. Analyses excluded twin gestation, diabetes, and hypertension. The overall incidence of deliveries at or before 36 weeks was 28% (31 of 112). Thirteen (12%) of the infants were small for gestational age (SGA) and 33 (29%) were low birth weight (LBW). Almost all subjects with a history of cocaine abuse had normal systolic-diastolic ratios (S/Ds). All patients with abruption had abnormal S/Ds, as did 14 of 64 subjects who had preterm labor and a history of cocaine abuse. No abnormal S/Ds were found in the women with preterm labor or in controls. Among cocaine-abusing women, there was a significant correlation between placental abruption and abnormal S/Ds (P less than .05) and between abnormal S/Ds and the incidence of preterm birth and SGA and LBW infants.     

Evaluation of fetal intrapartum hypoxia by middle cerebral and umbilical artery Doppler velocimetry with simultaneous cardiotocography and pulse oximetry

Objective To investigate fetal circulation at different stages of hypoxia during labor, and to study blood flow alterations in the brain and peripheral tissues, through simultaneous use of three non-invasive techniques.Materials and methods Ninety two pregnant women between 38 and 41 weeks of gestation, comparable for maternal age and parity, were simultaneously monitored with cardiotocography (CTG), continuous fetal pulse oximetry and Doppler ultrasonography during the first stage of labor. In 70 cases evaluation was successful, and useful data was obtained. Doppler waveforms were obtained before and during abnormal CTG patterns, of both the umbilical (UA) and middle cerebral artery (MCA) to measure the pulsatility index (PI), resistance index (RI), and flow velocity integral (FVI). The study population was divided in three groups, according to CTG and fetal pulse oximetry tracings: 20 term fetuses with normal CTG patterns and oxygen saturation (FSPO₂) values >40%, 30 term fetuses with abnormal CTG patterns and FSPO₂ values between 30 and 40%, and 20 fetuses with abnormal CTG patterns and FSPO₂ values <30% for a time up to 2 min. These were studied and peripartum outcomes were compared.Results Redistribution of blood flow was noted at FSPO₂ values of 37%, in all groups. In the presence of reduced oxygen saturation (near to or below 30%), MCA Doppler showed significantly lower PI (1.06±0.33 vs.0.74±0.39, p=0.03) and RI (0.59±0.14 vs. 0.44±0.14, p=0.03), while that of the UA showed mildly higher resistance indices (0.98±0.14 vs. 1.28±0.50, p=0.01 and 0.57±0.12 vs. 0.79±0.24, p=0.004, respectively). When an oxygen saturation value of <30% was maintained for greater than 2 min, MCA Doppler indices reversed, likely indicating morbid fetal hypoxia. Differences in fetal outcomes between groups correlated with Doppler and pulse oximetry tracings.Conclusions During active labor the fetus maintains oxygen supply to the brain by redistributing blood flow. In cases of hypoxia this is feasible for only 2 min. We note a strong correlation between fetal pulse oximetry, Doppler velocimetry of the MCA and UA, and fetal morbidity.     

Maternal glycemic control and umbilical artery Doppler velocimetry

Objective: To determine whether information from umbilical artery Doppler flow velocity waveforms significantly improves the prediction of adverse perinatal outcome, independently of maternal glycemic control, in pregnancies complicated by diabetes. Study design: The medical records of 277 pregnant women with diabetes were reviewed. Glycemic control was determined by glycosylated hemoglobin concentration and umbilical artery Doppler velocimetry by using systolic/diastolic ratios (S : D), both obtained during the third trimester. Pregnancies with adverse perinatal outcome were compared to those with good outcome. Logistic regression analysis was used to adjust for glycemic control, and to test whether an elevated umbilical artery Doppler S : D ratio was independently associated with pregnancy outcome. Results: Adverse pregnancy outcome occurred in 51.6% of these pregnancies (143/277). The mean third-trimester glycosylated hemoglobin (7.7 ± 1.9% vs. 6.7 ± 1.3%, p < 0.001) and the umbilical artery S : D ratio were significantly higher (2.6 ± 0.6 vs. 2.4 ± 0.3, p < 0.001) in the pregnancies with adverse outcome. Logistic regression analysis showed that umbilical artery S : D ratio was an independent predictor of adverse perinatal outcome after adjusting for the third-trimester glycosylated hemoglobin level. Forty per cent of patients with normal Doppler findings (S : D ratio of < 3.0) and normal glycemic control values (glycosylated hemoglobin level of < 7.5%) had an adverse pregnancy outcome. Sixty-three per cent of patients with an abnormal result for one of these tests had an adverse pregnancy outcome. Ninety-six per cent of patients with both abnormal Doppler findings and abnormal glycemic control had an adverse pregnancy outcome. Conclusion: Umbilical artery Doppler velocimetry improves the predictive value for adverse perinatal outcome, independently of glycemic control, in pregnancies complicated by diabetes. The combination of an abnormal umbilical artery S : D ratio and abnormal glycosylated hemoglobin was strongly associated with adverse pregnancy outcome.     

Fetal Doppler: umbilical artery, middle cerebral artery, and venous system

One of the most important applications of Doppler ultrasonography in obstetrics is the detection of fetal anemia in pregnancies complicated by either red-cell alloimmunization or by other causes of fetal anemia. Doppler of the umbilical artery also has prognostic value in pregnancies affected by twin-twin transfusion syndrome undergoing in-utero intervention. Another potential major application is the use of Doppler ultrasound in the management of intrauterine-growth-restricted fetuses. At the present time, there is no single test that appears superior to the other available tests for timing the delivery of the growth-restricted fetus. Therefore, the decision to deliver a fetus, especially at <32 weeks, remains mostly based on empirical management. Doppler may provide a more reliable and systematic basis for timing these deliveries. This review emphasizes the three following concepts: (a) normal and abnormal Doppler of the umbilical artery, middle cerebral artery, mitral and tricuspid valves, umbilical vein, and ductus venosus; (b) some clinical applications of Doppler sonography in obstetrics; and (c) potential future research of Doppler in obstetrics.     

Doppler umbilical artery velocimetry in fetuses with polyhydramnios

Polyhydramnios is a condition of multiple etiologies, many of a benign nature, but some of which are incompatible with life. To evaluate Doppler velocimetry results as a prognostic parameter in these fetuses, we reviewed all of our cases of polyhydramnios that underwent Doppler analysis in the third trimester. Fifty-four fetuses were studied. Eleven (20.4%) had abnormal waveforms and 43 (79.6%) had normal waveforms. An abnormal waveform was associated with a significantly higher incidence of congenital anomalies, perinatal mortality and intrauterine growth retardation. Six of the 11 fetuses had abnormal karyotypes. Macrosomia was present in 37.2% of fetuses with normal waveforms and in no fetus with an abnormal waveform. Doppler analysis may aid in the counseling and management of patients with polyhydramnios. In cases with an abnormal ratio, the physician and patients should be prepared for a poor outcome and third trimester genetic analysis should be strongly considered.     

Uterine and umbilical artery Doppler velocimetry in postterm pregnancy

Uterine and umbilical artery Doppler velocimetry was carried out on 149 women whose pregnancies went to 41 weeks or beyond. Flow velocity was not altered even in the presence of other signs suggestive of fetal compromise. It appears that the postdate syndrome is not associated with significant alterations in the maternal or umbilical blood flow prior to the onset of labor.     

Fetal middle cerebral and umbilical artery Doppler after 40 weeks gestational age

Abstract

Objective: To determine the value of fetal Doppler indices named middle cerebral artery (MCA)-PI, umbilical artery (UA)-PI and MCA-PI/UA-PI ratio, and amniotic fluid volume assessment in pregnancies 280–294?d and their correlation with the mode of delivery and perinatal outcome.

Study design: Prospective observational study conducted on 100 whose gestational age (GA) from 40 to 42 weeks. MCA and UA Doppler and MCA-PI/UA-PI ratio, amniotic fluid volume (AFV) were assessed. They were divided into two groups based on the presence or absence of adverse perinatal outcome.

Results: Women with adverse perinatal outcome showed lower MCA-PI (0.92 versus 1.29), MCA-PI:UA-PI ratio (1.04 versus 1.83), lower gestational age when assessed by ultrasound (37.82 versus 39.48 weeks), lower neonatal birth weight (2705 versus 3108?g), fetal biophysical profile (BPP) (4.55 versus 7.21) when compared to women with normal perinatal outcome. They also had higher cases with oligohydramnios (34 versus 5), and higher UA-PI (0.89 versus 0.72).

Conclusion: Women with adverse neonatal outcome had higher UA-PI and lower MCA-PI, MCA-PI:UA-PI ratio, GA (by US), AFV, BPP, estimated fetal weight, neonatal birth weight when compared to those with normal perinatal outcome. Women with adverse neonatal outcome had a higher rate of cesarean section mostly due to fetal distress and induced VD due to oligohydraminos compared to the normal outcome group.     

Relationship between second trimester maternal serum alpha-fetoprotein and umbilical artery Doppler velocimetry and their association with preterm delivery.

One explanation for an abnormal maternal serum alpha-fetoprotein (MSAFP) may be an abnormal placenta. A specimen for MSAFP and a series of umbilical artery waveforms were obtained prior to amniocentesis from 144 consecutive women referred for either maternal age (n = 85), a persistently elevated MSAFP unassociated with a structural abnormality (n = 42), or a low MSAFP (n = 17). Almost 50% of deliveries before 37 weeks and 60% of neonatal birthweights below the tenth percentile occurred in the high MSAFP group. We observed that the systolic-diastolic ratio (S/D), pulsatility index, and resistance index tended to be higher in women referred for an elevated MSAFP. Confining analyses to the elevated MSAFP group, the MSAFP in multiples of the median correlated with birthweight independent of the gestational age at delivery (p less than 0.001). In addition, the S/D related directly to MSAFP (p less than 0.03) and indirectly to the gestational age at delivery (p less than 0.04). None of these relationships was observed in the groups of women referred for either maternal age (who had a normal MSAFP) or a low MSAFP. Employing a stepwise multiple linear regression, we found that the gestational age at delivery could be predicted during the midsecond trimester using a combination of the umbilical artery S/D and MSAFP. When the analyses and predictions were limited to subjects whose MSAFP still exceeded 2 multiples of the median at the time of amniocentesis, the positive predictive value for preterm delivery was 100% and the negative predictive value was 93%.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of betamethasone on fetal biophysical activities and Doppler velocimetry of umbilical and middle cerebral arteries.

OBJECTIVE: Preliminary reports suggest that antenatal steroid administration may confound the assessment of fetal well-being by suppressing biophysical activities, consequently drug-induced effects could prompt unwarranted delivery of premature fetuses. The purpose of this study was to examine the effect of antenatal betamethasone administration on fetal biophysical activities and Doppler flow indices of the umbilical and middle cerebral circulation. METHODS: Forty women at risk of premature delivery between 27-32 weeks gestation (mean 30.2 weeks) received two consecutive doses of intramuscular betamethasone, 24 hours apart. Ultrasonographic observations of fetal behavior for 30 minute periods and Doppler examination of the umbilical and cerebral arteries were performed prior to (0 hours), 48 hours after, and 96 hours after administration of the first dose. To account for fetal circadian rhythms and maternal prandial status, all examinations were carefully timed and performed between 1-4 pm. Analysis of Variance, chi-square test and Fisher's Exact test were used for statistical analysis, as appropriate. RESULTS: Nine patients were excluded from analysis due to delivery prior to completion of all examinations. Number of breathing episodes as well as total breathing time at 48 hours decreased by 83.0% (p<0.01) and 90.4% (p<0.01), respectively, at 48 hours in comparison to baseline. Fetal limb and trunk movements decreased by 53.2% (p<0.01) and 48.6% (p<0.01), respectively. Amniotic fluid volume and fetal tone were normal in all patients. At 48 hours, 14 of 31 fetuses and 4 of 31 fetuses had a biophysical profile score of 6/8 and 4/8, respectively, in comparison to 0 of 31 and 0 of 31 at 0 hours (p<0.05 and p<0.001, respectively). All parameters returned to baseline values at 96 h. Pulsatility indices of umbilical and middle cerebral arteries remained unchanged at 48 hours and 96 hours (p=NS). CONCLUSIONS: Betamethasone induces a profound, albeit transient, suppression of fetal breathing, limb and trunk movements, resulting in decreased biophysical profile scores. Awareness of this drug-induced effect might prevent unnecessary iatrogenic delivery of preterm fetuses.     

Doppler velocimetry in the fetus with a single umbilical artery.

OBJECTIVE: To study Doppler velocimetry in fetuses with a single umbilical artery (SUA) as compared to normal. STUDY DESIGN: Private and clinic patients were referred to a perinatal center: 45 with SUA and 124 randomly selected fetuses with a three-vessel cord were studied from 18 to 41 weeks' gestation. Color Doppler flow and energy were utilized to evaluate the umbilical arteries at the fetal abdominal wall as well as the course around the bladder. In addition to Doppler velocimetry, an anatomic survey, estimated fetal weight (EFW) and amniotic fluid index (AFI) were assessed at each examination. RESULTS: Doppler velocimetry in SUA demonstrated indices in the normal range but lower than in normal cords from 26 weeks until near term. Anatomic anomalies were found in 8.9% of SUA as compared to 4.8% for three-vessel cords. Intrauterine growth restriction (IUGR) was seen in four cases of SUA and none in the control group. EFW and AFI for both groups were virtually identical. CONCLUSION: SUA cords theoretically carry a normal blood volume, and the decreased resistance to flow and larger arterial diameter allow this to occur. Anomalies and IUGR are elevated in infants with SUA. Overall, EFW and AFI were the same in both groups of patients.     

Maternal middle cerebral artery velocimetry in normal pregnancy and postpartum

Objective To study changes throughout gestation and the puerperium of middle cerebral artery flow velocity waveforms obtained by transcranial Doppler ultrasound.
Design Prospective, observational study.
Setting John Radcliffe Maternity Hospital, Oxford, UK.
Participants and Methods Middle cerebral artery velocities were measured by transcranial Doppler ultrasound in 25 nonpregnant women, 22 women longitudinally followed throughout pregnancy and 21 women serially studied from delivery until the late puerperium.
Main outcome measures Transcranial Doppler changes in pregnancy and the puerperium.
Results The transcranial Doppler ultrasound measurements showed good reproducibility. Signals from one middle cerebral artery could not be obtained in 4.6% of the examinations, but otherwise readings were similar on both sides. Women in the second half of pregnancy had lower middle cerebral artery mean velocities than nonpregnant women. Velocities decreased with advancing gestation but increased in the immediate puerperium to levels comparable to those found in nonpregnant women.
Conclusions Transcranial Doppler ultrasound is a noninvasive technique suitable for studying maternal cerebral haemodynamics in pregnancy and postpartum. Middle cerebral artery mean velocity decreased with advancing gestation and increased to nonpregnant values in the immediate puerperium. These physiological changes need to be considered when comparing data with measurements taken in abnormal pregnancy states.     

Doppler umbilical artery velocimetry in pregnancies complicated by intrahepatic cholestasis.

Doppler umbilical velocimetry is a useful clinical tool for antepartum fetal surveillance of pregnancies at risk of fetal compromise. Intrahepatic cholestasis of pregnancy is associated with an increased incidence of fetal death, which might due to the toxic effect of elevated maternal serum concentrations of bile acids. To study a possible effect of the concentration of bile acids on the umbilical circulation we performed pulse-wave Doppler velocimetry of the umbilical artery in 15 patients with intrahepatic cholestasis between 34 and 38 weeks of gestation. The findings were compared to the Doppler flow velocities of the umbilical artery of 129 normal pregnancies. Peak-systolic (A) and end-diastolic (B) velocities of two to three cardiac cycles were measured by electronic calipers and the Pourcelot (PR)-index (PR = (A - B)(A)) was calculated. Two of 29 Doppler measurements in patients with intrahepatic cholestasis were above two standard deviations (2 SD) of the values in normal pregnancies. No significant correlation was found between Doppler flow velocities and serum levels of bile acids (r = 0.20) or the levels of alanine aminotransferase (ALAT) (r = -0.05). The mean level of bile acids was 24 mumol/l with a maximum of 98 mumol/l. The mean level of ALAT was 165 IU/l with a maximum of 576 IU/l. Since even high levels of bile acids do not influence umbilical circulation, Doppler investigations of the umbilical artery seem to be of little value in studying the disease-specific risk of fetal compromise in pregnancies complicated by intrahepatic cholestasis.     

Doppler umbilical artery velocimetry in pregnancy complicated by insulin-dependent diabetes mellitus

The mean peak systolic to end-diastolic (S/D) umbilical artery ratio was measured in 291 Doppler studies performed during pregnancy in 35 insulin-dependent diabetic women. A normal decline was observed in the umbilical artery S/D ratio, from 4.2 +/- 0.21 at 18 weeks to 2.18 +/- 0.22 at 38 weeks. There was no significant correlation between mean third-trimester S/D and either glycosylated hemoglobin (r = 0.25) or mean blood glucose levels (r = 0.15). Fetuses of women with vascular disease (class F/R or chronic hypertension) had a mean third-trimester S/D of 3.0 or higher in five of ten cases, compared with three of 25 in patients with uncomplicated diabetes (P less than .03). Mean second- and third-trimester S/D ratios differed significantly in patients with and without vascular disease: 4.34 +/- 0.7 and 3.2 +/- 0.65 versus 3.72 +/- 0.42 and 2.55 +/- 0.32, respectively (P less than .03). Two of three women without vascular disease who demonstrated an elevated mean S/D ratio developed preeclampsia and delivered appropriate for gestational age infants. In women with vascular disease, four of five with an abnormal mean third-trimester umbilical artery S/D ratio were delivered of growth-retarded infants, whereas all five with normal umbilical artery S/D ratios had appropriate for gestational age infants. In three of the abnormal cases, elevated S/D ratios were present in the second trimester before ultrasound documentation of fetal growth retardation.(ABSTRACT TRUNCATED AT 250 WORDS)     

胎儿脐动脉及大脑中动脉阻力参数正常值

目的了解本地区低危人群胎儿脐动脉（umbilical artery，UA）及大脑中动脉（middle cerebral artery，MCA）搏动指数（pulsatility index，PI）、阻力指数（resistance index，RI）、收缩期峰值流速与舒张末期流速比值（S／D）的正常参考值范围。方法随机选取2218例孕20～40周的无合并症单胎孕妇，检测脐动脉（近胎儿侧）及大脑中动脉（中段）血流，记录PI、RI、S／D进行分析。结果脐动脉的血流阻力随着胎龄的增加而降低，大脑中动脉的血流阻力在孕20-26周随孕周的增加而增高，孕26～28周时达高峰，28周以后随着孕周的增加而降低。结论了解胎儿脐动脉及大脑中动脉血流阻力在不同孕周的变化规律，对判断及随访胎儿宫内缺氧状况，协助临床做出正确的产科处理具有重要意义。     

Prediction of perinatal outcome by middle cerebral artery doppler velocimetry

The relationship between pulsatility index (PI) in the middle cerebral artery (MCA) and adverse perinatal outcome was studied in 162 normal and 75 high-risk pregnancies. The intrapartum cardiotocographic (CTG) findings, the mode of delivery, 1 and 5-minute Apgar scores, the pH level of the umbilical artery, admission to the neonatal intensive care unit (NICU) and the incidence of intrauterine fetal growth retardation were recorded. In the low risk group, the PI values in the MCA were only affected in growth retarded fetuses (P = 0.0084). In the high-risk group, there was an association between the MCA PI values and 5-minute Apgar scores (P = 0.0397), umbilical artery pH values (P = 0.0068) and development of IUGR (P = 0.0376). In both groups, an abnormal intrapartum CTG, the 1-minute Apgar score, cesarean section for fetal distress and admission to the NICU were not related to PI values in the MCA. Our present study suggests that doppler flow measurement of MCA provides useful information about perinatal outcome, especially in the high-risk pregnancies. Received: 19 January 1995 / Accepted: 5 February 1996     

Combined use of the cardiofemoral index and middle cerebral artery Doppler velocimetry for the prediction of fetal anemia

Objective

To assess the accuracy of the combined use of the cardiofemoral index (CFI) and the middle cerebral artery peak systolic velocity (MCA-PSV), converted to multiples of the median (MoM), as noninvasive means to detect severe fetal anemia.

Method

We measured CFI and MCA-PSV MoM in 37 fetuses just before their first (n = 37), second (n = 22), and third (n = 14) cordocenteses and transfusions. Then, using 2 different criteria for severe fetal anemia detection (Hb deficit ≥ 7 g/dL and hemoglobin level ≤ 0.55 of MoM), we assessed their hemoglobin status during cordocentesis and the accuracy of CFI and MCA-PVS was determined.

Results

At the first cordocentesis the mean hemoglobin level was 8.5 ± 3.6 g/dL and 15 fetuses (40.5%) had hydrops. In a total of 81 fetal evaluations, 58 (71.6%) of the CFIs and 34 (42.0%) of the MCA-PSV MoM measurements were abnormal. The result of one of these tests was abnormal in 65 evaluations (80.3%) and the results of both tests were abnormal in 27 evaluations (33.3%). All fetuses diagnosed as being severely anemic by at least one of the hemoglobin criteria during cordocentesis had an abnormal result by at least one of the noninvasive tests. Before the second and third transfusions, the combined use of the CFI and MCA-PSV MoM predicted severe fetal anemia with 100% sensitivity. When the CFI and MCA-PSV MoM measurements were normal, the negative likelihood ratio was zero.

Conclusion

When associated, CFI and MCA-PSV MoM were accurate predictors of severe fetal anemia.