1. COLOR DOPPLER IN FETAL
GROWTH RESTRICTION AND
HYPOXIA
narendra malhotra
jaideep malhotra
neharika malhotra bora,rishabh bora,
keshav malhotra
Acknowledgments:
asim kujak,ashok khurana,jayprakash shah
www.malhotrahospitals.com
www.rainbowhospitals.org
2. IMPORTANCE
THE ACCURACY OF DOPPLER VELOCIMETRY IN
CONJUNCTION WITH 2D ULTRASOUND AND
COLOR FLOW MAPPING IS NOW REGARDED AS
AN INDISPENSABLE COMPONENT OF A
PREGNANCY SONOGRAM
4. COLOR DOPPLER STUDIES
ESTABLISHED FACTS
IDENTIFY THE FETUS AT RISK FOR
DAMAGE OR DEATH IN UTERO
ARE AN ESTABLISHED TOOL TO ASSESS
MODE AND TIMING OF DELIVERY
PREDICT REASONABLY WELL THE FETUS
AT RISK FOR A GROWTH DISORDER
IMPROVE PREGNANCY OUTCOMES
5. COLOR DOPPLER STUDIES
ESTABLISHED UTILITY
HIGH RISK PREGNANCY
FETAL WELL-BEING
RISK OF CONTINUED INTRAUTERINE EXISTENCE
LOW RISK PREGNANCY
IDENTIFYING A SUB-GROUP OF FETUSES
THAT NEED INCREASED SURVEILLANCE
7. COLOR DOPPER IN IUGR
METHODOLOGY
NORMAL FETAL CICULATION
HYPOXIA-REDISTRIBUTION MECHANISM IN IUGR
MANAGEMENT STATEGIES
8. PART I :METHODOLOGY
3.5- or 5-MHz curved-array transducer
Spatial peak temporal average intensities <100
mW/cm2.
High-pass filter - 125 Hz.
Size of the sample volume adapted to the
vessel diameter to cover it entirely.
Recordings for measurements were obtained in
the absence of fetal breathing movements and
fetal heart R between 120 -160 bpm
The angle between the ultrasound beam and the
direction of blood flow was always less than
50°.
18. Organ-sparing effects
Heart and brain sparing act
synergistically with venous and
arterial redistribution.
Both of these organs derive their
blood supply from the left ventricle.
Vasodilatation at the organ level acts
synergistically to increase organ
blood flow.
19.
20. Doppler vessels to be studied
MATERNAL SIDE
Uterine artery
PLACENTAL SIDE
Umbilical a
FETAL SIDE
Arterial:mca,fetal a,renal and others
Venous:ductus,hepatic,umbilical
Fetal echocardiography
21. UTERINE ARTERIES
REFLECTS : TROPHOBLASTIC INVASION
END POINTS :
ELEVATED RESISTIVE INDICES (>2SD)
PERSISTENT DIASTOLIC NOTCHING
PRESENCE OF SYSTOLIC NOTCHING
MAJOR LEFT TO RIGHT VARIATION
26. Utero placental circulation
Uterine Artery
Normal impedance
to flow the uterine
arteries in 1º
trimester
Normal impedance
to flow the uterine
arteries in early
2ºtrimester
Normal impedance
to flow the uterine
arteries in late 2º
and 3º trimester
27. Uterine artery
At 24 weeks
No Dichrotic Notch
PI < 1.2
Routine Screening
Pre eclampsia & it’s severity can be predicted
Monitoring of fetus
32. Umbilical artery Flow
S/D ratio 2-3 in 2nd & 3rd
trimester
PI
1.5 – 2.0 in 2nd trimester1.0 –
1.5 in 3rd trimester
RI
decreases with gest. In late Whether at fetal end,
2nd and 3rd it is around 0.5 placental end or in
between – no difference
33. Umbilical Artery flow What does it
tell us ??
First sign of hypoxia & growth retardation
34. Utero-placental
circulation
Umbilical
artery
progressive
maturation of
the placenta
and increase in
the number of
tertiary stem
villi.
35. Umbilical Artery
Changes in
umbilical artery
waveform are
evident only
when 60% of
Placental blood
flow is
obliterated
36. Normal Umbilical Artery
1º trimester
Absent Diastolic Flow
early 2ºtrimester
Low Diastolic Flow
late 2º and 3º
trimester
Resistance further
reduce, more diastolic
flow
37. Umbilical Artery - Abnormal
Umbilical arteries
- normal
Umbilical arteries
- high pulsatility index
Umbilical arteries
- Absent end diastolic velocity
- very high pulsatility index.
- pulsation in the umbilical vein
Umbilical arteries
reversal of end diastolic
39. Umbilical Artery
Cordocentesis was carried out in 39 IUGR fetuses
Positive Diastolic Flow 12% Hypoxic
00% Acidemic
Absent / Reverse Diastolic 80% Hypoxic
Flow 46% Acidemic
Nicolaides
40. N = 459 Umbilical Artery
Flow in Umbilical No of Relative Risk
Artery fetus of Mortality
Positive End 214 1
Diastolic Flow
Absent End 178 4
Diastolic Flow
Reverse End 67 10.6
Diastolic flow
Clinical significance of absent or reversed end diastolic velocity waveforms in
umbilical artery. Lancet 1994;344:1664–8
41. Absent / Reverse End Diastolic Flow
Risk to Neonate
More admissions to NICU
Increase ICH
Increase Anemia
Increase Hypoglycemia
Increase long term permanent neurological damage
High Resistance Reversal of Diastole
42. Umbilical artery & CTG
Umbilical artery 90% more sensitive to
CTG
Interval between absence of end
diastolic flow & onset of late
deceleration was 3-12 days
High Resistance Bekedam DJ et al. Early Hum Dev 1990;24:79–89
47. Middle cerebral artery
Decompensation
Brain sparing effect may be transient
Overstressed fetus can lose the brain sparing effect.
Disappearance of brain sparing effect - very critical
event for the fetus- precedes fetal death.
MCA may have tremendous implication for determining
the proper timing of delivery.
58. FETAL ILLNESS AND USG
PATHOLOGICAL DECREASE IN RATE OF GROWTH
(ULTRASOUND B MODE)
SOONER OR LATER GROWTH RESTRICTED FETUSES
BECOME HYPOXEMIC,HYPOXIC AND ACIDOTIC (THIS
CAN BE DIAGNOSED BY DOPPLER)
FETAL ILLNESS IS RELATED TO FETAL,MATERNAL
AND PLACENTAL CAUSES
MOST FREQUENT ETIOLOGY OF A SICK FETUS IS
MILD TO MODERATE UTEROPLACENTAL INSUFF DUE
TO P.I.H.
59. Markers For Fetal illness
AFI Chronic Marker
NST
FT Acute Markers
FM
FBM
60. Manning’s Biophysical Profile
NST
FBM
FM
FT
AFI
Maximum score 10 Minimum 0
Oligohydramnios indicates abnormal BPP
regardless of the total score of others
62. Modified Biophysical Profile (MBPP)
VAST with NST for index of acute hypoxia
® AF Volume – index for chronic fetal problems
® Excellent negative & positive
predictive values (Vintzielos)
® Can be performed in 20 mins.
63. FETAL BPP VS DOPPLER
AMNIOTIC FLUID IS DUE TO PLACENTAL
FUNCTION ,FETAL URINATION,FETAL
SKIN,UMBILICAL CORD AND THE BLOOD
VOLUME.
AT EARLY PLACENTAL HYPOFUNCTION THE AFI
REMAINS NORMAL,NOR IS THE AFI REDUCED IN
ACUTE HYPOXIA
THIS PHASE OF F.G.R IS DECEPTIVE TO BPP
AND IT IS THIS WHICH IS PICKED UP BY
DOPPLER B’COS BY THIS TIME DOPPLER WILL
SHOW AEDF OR REDF AND ABNORMAL VENOUS
FLOW
HENCE WAITING FOR LESS LIQ WILL DELAY THE
64. Hypoxia & Markers
Umb. pH at which abnormal Test
7.20 Abnormal NST
<7.20 FBM
7.10 - 7.20 Movements
< 7.10 Tone
This should be kept in mind for interpretation of Hypoxia and
acidosis
65. Time to deliver
Factors to decide time to deliver
Degree of Prematurity
NICU facility
Degree of Hypoxia, acidemia, hepatic metabolic
derangement
Challenge to weigh the risks and benefits of
interventions
66. Time to deliver
When you want to deliver?
? Mild to moderate Hypoxia
? Moderate Hypoxia with early acidemia
?? Severe hypoxia with moderate to severe acidemia
& hepatic metabolic derangements
Best time when fetal redistribution mechanism start
failing
67. Take Home Message
Doppler is very sensitive to detect fetal hypoxia &
acedimia
Serial doppler study is required to decide time of
delivery to reduce the perinatal morbidity & mortality
68. Low-Risk
Suggestions
If Doppler is available
It may identify a fetus with IUGR who
registers later and you are uncertain
of the gestational age
Doppler French Study Group
Br J Obstet Gynecol 1997, 104:419
87. Decompensation- aortic isthmus
When the net flow in
the AI becomes
retrograde-Nutrient
and O2 content of the
LV drops -- increased
risk for adverse
childhood
neurodevelopment in
fetuses .
89. CARDIAC FAILURE -VENOUS BLOOD FLOW
Retrograde flow in IVC
, DV with atrial
contraction
UV pulsations
90. Staging of growth restricted fetus:
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
91. stage I
an abnormal umbilical artery or middle cerebral artery
pulsatility index;
92. stage II
an abnormal MCA PSV,
absent/reversed diastolic velocity
in the UA,
UV pulsation and an abnormal DV PI
(an absent DV A wave is considered
part of this
stage)
93. 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.
94. Each stage divided in A & B
A is AMNIOTIC FLUID INDEX <5
B is AMNIOTIC FLUID INDEX OF >5
95. The rationale for the division of IUGR fetuses
into 3 stages was based on the results of previous
studies in which we serially determined the
changes of 15 Doppler parameters occurring in
IUGR fetuses from the time the diagnosis was
made up to delivery.On the basis of results of
those studies, we should have divided the set of
IUGR fetuses into 15 stages, but to keep the staging
as a practical diagnostic tool, we limited it to
3 stages.
96. MANAGEMENT STRATEGIES
Mild utero-placental insufficiency
No effect is seen on Doppler and growth until
26-32 weeks gestation.
The umbilical artery and the middle cerebral
artery waveforms may be abnormal
However process is not severe enough to stop
fetal growth completely or to deteriorate
These cases may be followed with outpatient
monitoring and they often deliver at term.
97. Assessment of IUGR Fetus
Biometry
Fetal assessment for malformation
AF
Fetal Activity (Biophysical Profile)
Color Doppler
99. What Kind of Information on CD ?
Utero placental circulation – Predictive
Uterine Artery & Umbilical Artery
Fetal Arterial Circulation – Cut Off Line
Redistribution of Blood & brain Sparing Effect
Fetal Venous Circulation - Decision
Timing of Delivery
Degree of acidemia & Hypoxia
100. Changes due to Hypoxia
When > 50% placenta is not functioning
Mild Hypoxia – Umbilical artery
When > 70% placenta not functioning
Moderate Hypoxia -> Compensatory redistribution in
MCA
When > 90% placenta not functioning
Severe Hypoxia -> Failure of Compensatory
redistribution - DV
101. How to Judge Degree of Hypoxia?
Fetal arterial doppler
Cut off Line
102. Fetal arterial circulation
Fetal Arterial Circulation – Cut Off Line
Redistribution of Blood & brain Sparing Effect
Compensatory Redistribution
More flow of oxygenated blood Less flow of oxygenated blood
Brain Kidneys
Myocardium GIT
Fetal adrenal Limbs, Lungs
MCA – Nadir reached 2 weeks before fetal jeopardy
104. MCA flow
PI
More than 1.45 before term
Fall down to 1
If less than 1 peak of
redistribution
105. How to Judge degree of Acidemia?
Fetal Venous doppler
106. Fetal Venous Doppler
The PI of the middle cerebral was the best predictors
of hypoxemia,
DV flow was the best predictor of Acidemia and hyper
capnia.
Fetal Venous Doppler
IVC
Rizzo et al.
Ductus Venosus
Br J Ob Gyn 1995; 102:963-69
Umbilical Vein
SVC
108. Umbilical Vein
study of 37 fetuses ~~ absent end-diastolic frequencies
in the umbilical artery
Neonatal mortality
• in group with pulsatile venous flow was 63%,
• In group without pulsation was 19%
Arduini D, Rizzo G et al Am J Obstet Gynecol 1993;168: 43–50