Interpretation of Doppler during pregnancy

1. Interpretation
of Doppler
during
pregnancy
Aboubakr Elnashar

2. Aboubakr Elnashar

3. I. Umbilical artery Doppler
Idea:
Umbilical Arterial Flow is normally of low resistance.
In hypoxic states:
relative placental hypoxia:
reactive VC of umbilical artery:
higher resistance:
decrease in diastolic flow
Aboubakr Elnashar

4. Interpretation:
 Resistance index:
 best ability to predict abnormal outcomes
(RCOG,2002 Evidence level II)
 Enddiastolic flow
 Systolic/diastolic ratio
 Pulsatility index
 Diastolic average ratio
Aboubakr Elnashar

5. Doppler indices
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6.  Resistance Index:
 In normal pregnancy:
{progressive increase in end-diastolic velocity
{growth& dilatation of the umbilical circulation}:
Resistance index falls.
 In IUGR and/or PET:
> 0.72 is outside the normal limits from 26 w.
Aboubakr Elnashar

7. End Diastolic flow
 In IUGR and/or PET:
reduced, then
absent (AED) or
reversed (RED) in severe cases
 Absent or reversed:
Fetal distress is almost certain:
Immediate BPP or NST or
Delivery may be indicated.
Aboubakr Elnashar

8. S/D
Should be <3.
Small increases in S/D= 3-5:
IUGR.
Not strictly useful:
1. low sensitivity.
2. Gestation age dependent.
Aboubakr Elnashar

9. Surveillance= frequency of monitoring
Every 14 days.
in SFGA with normal Doppler
More frequent:
severe SGA
 Twice weekly:
abnormal Um A D
(PI or RI > +2 SDs above mean for ges age) and
end–diastolic velocities present
Daily:
AED/RED
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10. Normal
Absent
Reversed
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11. Normal
Absent
Reversed
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12. RED
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13. RED
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14. Advantages
In low risk
No benefit on mother or baby
(Cochrane Library, 2003)
 In high risk:
 Reduction of
perinatal morbidity and mortality
number of antenatal admissions
inductions of labor
resources compared with CTG
(Grade A RCOG, 2002; The Cochrane Library, 2003)
 Comparing FHR monitoring, FBP and umbilical
artery Doppler:
only umbilical artery Doppler had value in predicting
poor perinatal outcomes in SGAAboubakr Elnashar

15. SMFM Clinical Guideline, 2012
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16. II. Middle cerebral artery
In preterm SGA:
limited accuracy: should not be used
In term SGA:
Normal Um A D, an abnormal MCA D
(PI < 5th centile) has moderate predictive value
for acidosis at birth: used to time delivery.
Aboubakr Elnashar

17. In fetal anemia:
Enhanced fetal cardiac output and
Decrease in blood viscosity:
Increased blood flow velocity
preferentially shunt blood to brain faster
most pronounced MCA PSV
Aboubakr Elnashar

18. Frequency
•Initiated: 18 w
•Repeated: every 1–2 w as the clinical situation
MCA waveforms in an anemic
fetus requiring serial
transfusions for severe Rh (D)
disease.
The peak systolic velocities of
62, 50, and 61 cm per second
(top to bottom) corresponded to
fetal hematocrits of 19%, 44%,
and 32%, before, at the time of,
and a week after the first
intravascular transfusion,
respectively.
Aboubakr Elnashar

19. Aboubakr Elnashar

20. Advantage
More sensitive for predicting f anemia than the
ΔOD450
Alternative to serial amniocenteses
Excellent noninvasive tool for the monitoring of f
anemia.
Aboubakr Elnashar

21. IUGR
Normal
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22. A: The normal MCA flow pattern has
relatively little diastolic flow
B: With elevation of placental blood
flow resistance the changes in MCA
wave form may be subtle, although
the cerebroplacental ratio may
become abnormal.
C: With progressive placental
dysfunction: an increase in the
diastolic velocity: decrease in the
Doppler index (Brain sparing)
D: With marked brain sparing, the
systolic down slope of the waveform
becomes smoother: waveform almost
resembles that of the umbilical artery.
The associated rise in the mean
velocity: marked decline in the
Doppler index.Aboubakr Elnashar

23. III. Ductus venosus (DV)
Moderate predictive value
used in:
preterm SGA with abnormal Um A D and to time
delivery.
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27. Aboubakr Elnashar

28. IV.Uterine artery Doppler
• limited use in predicting FGR and perinatal death
(Grade A, RCOG,2002).
• Abnormal uterine artery suggest:
maternal cause for the growth restriction
• Normal uterine artery Doppler suggest:
fetal cause
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29. Aboubakr Elnashar

30. UAD: Normal
UAD: notch,
decreased diastolic
flow
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31. Prediction of PET
(Uterine Doppler velocimetry)
• Persistence of a
Diastolic Notch in
uterine artery
waveform after 24 w
• Systolic/diastolic ratio
>2.6
• RI > 0.58 after 24
weeks.
Systole
Diastole
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32. Aboubakr Elnashar