ABSTRACT ID NO:1058
ASSESSMENT OF UTERINE ARTERY,
UMBILICAL ARTERY AND FETAL MCA
DOPPLER VELOCIMETRY AS PREDICTORS
OF ADVERSE OUTCOME IN
PREGNANCIES COMPLICATED BY THIRD
TRIMESTER OLIGOHYDRAMNIOS
INTRODUCTION
 Oligohydramnios occurs in about 3-5% of all pregnancies, more
commonly in the third trimester.
 Has a strong association with increased risk for perinatal morbidity and
mortality.
 Adverse outcomes associated with oligohydramnios area) IGUR
b) Structural abnormalities
c) Dysmaturity syndrome
d) Pulmonary hypoplasia
e) Fetal distress during labour
f) Contracture of joints
g) Cord compression
•
Etiology is multifactorial, but a major factor is uteroplacental insufficiency.
UTEROPLACENTAL INSUFFICIENCY
CHRONIC FETAL HYPOXIA
REDISTRIBUTION OF FETAL CARDIAC OUTPUT
DECREASED BLOOD SUPPLY TO MAJOR
SOURCES OF AMNIOTIC FLUID PRODUCTION
OLIGOHYDRAMNIOS
 Not all pregnancies complicated with oligohydramnios develop adverse
outcomes.
 Traditional methods of evaluation do not help to reliably distinguish those
with normal and adverse outcomes, resulting in aggressive management
of all cases.
 Fetal and maternal Doppler evaluation may provide insight into the
development of oligohydramnios since the major etiological factor is
thought to be fetal hypoxia due to uteroplacental insufficiency.
 The purpose of this study is to establish the predictive value of Doppler
velocimetry in identifying pregnancies complicated with oligohydramnios
that are at increased risk of developing adverse perinatal outcomes to
ensure a heightened regimen of antenatal surveillance and management
to reduce the incidence of further compromise and identify cases that may
require prompt termination.
AIMS AND OBJECTIVES
 To evaluate Doppler velocimetry of uterine artery, umbilical artery and fetal
MCA as predictors of adverse outcomes in pregnancies complicated by
third trimester oligohydramnios.
 To identify which Doppler indices are more sensitive and specific in
identifying fetuses at risk of developing adverse outcomes.
 To evaluate the incidence of adverse outcomes in borderline and severe
oligohydramnios.
MATERIALS AND METHODS
 Our study was conducted in 30 patients diagnosed with oligohydramnios
in the third trimester of pregnancy at our hospital.

INCLUSION CRITERIA
EXCLUSION CRITERIA
 All pregnant women
 Pregnancies complicated by
irrespective of gravida beyond
fetal anomalies (structural or
24 weeks of gestation with
chromosomal).
oligohydramnios AFI < 5 cm and
borderline oligohydramnios AFI
< 5-8 cm.
Singleton pregnancy.
 Multiple pregnancy.
Intact membranes.
 Patients with hypertension,
diabetes, Rh incompatibility.
WOMEN FULFILLING THE CRITERIA
AFI ESTIMATION– BORDERLINE/SEVERE
OLIGOHYDRAMNIOS
DOPPLER VELOCIMETRY OF UTERINE
ARTERIES, UMBILICAL ARTERY AND FETAL MCA
FOLLOW UP TILL DELIVERY
 All patients were followed up until after delivery with NST, BPP, FHRM. At the
time of delivery, gestational age ,mode of delivery, indication for LSCS, fetal
heart rate, nature of amniotic fluid, APGAR score, Birth weight and NICU
admission were all taken into account as parameters for identifying adverse
outcomes.
 The following parameters were considered as adverse perinatal outcomes:
 Preterm delivery
 Caesarean section
 Fetal distress
 Meconium stained liquor
 APGAR score <6 at 1 min, <7 at 5 min
 Low birth weight (< 10th percentile for gestational age)
 Still birth
 NICU admission
 For Doppler velocimetry, the following parameters were considered
abnormal:
In the uterine artery: RI,PI >95th percentile for gestational age.
Presence of diastolic notch.
In the umbilical artery: RI,PI,S/D RATIO> 95th percentile.
Absent/Reversed end diastolic flow
In the fetal MCA: RI,PI < 5th percentile for gestational age.
S/D ratio < gestational age
MCA PI/ Umbilical artery PI ratio < 1.08.
 Statistical analysis:
- Sensitivity, specificity, positive and negative predictive value for each of
the Doppler indices.
- Chi-Square / Fischer test for significance.
CASE NO-1
FIG- 1
FIG -2
FIG-3
This patient had borderline oligohydramnios (FIG-1), but a normal Doppler study.
Both uterine arteries had normal low impedance flow (FIG-2&3).
FIG - 4
FIG - 5
Umbilical artery showed normal low impedance flow (FIG-4).
Fetal MCA showed normal high impedance flow pattern (FIG-5).
CASE NO -2
FIG -6
FIG -7
This patient also had borderline oligohydramnios (FIG-6) but the
Doppler study was abnormal. The uterine arteries showed normal low
impedance flow (FIG-7).
FIG -8
FIG -9
The umbilical artery showed increased impedance with absent enddiastolic flow (FIG-8) while the fetal MCA showed normal high
impedance flow (FIG-9).
CASE NO -3
FIG - 10
FIG - 11
This patient had almost no liquor. The uterine arteries showed increased
impedance with persistent diastolic notch (FIG 10&11).
FIG -12
FIG -13
The umbilical artery showed high impedance flow with reduced end
diastolic flow (FIG-12). The fetal MCA showed reduced RI with
increased diastolic flow suggestive of brain sparing reflex (FIG-13).
RESULTS
 Majority of patients were primigravida (66.7%).
 Among 30 patients, 53.3% had Borderline oligohydramnios and 46.7%
had severe oligohydramnios.
 There was increased incidence of adverse outcomes in severe
oligohydramnios than borderline oligohydramnios (92.8% vs.75%).

In the study by Ravikant et al(7) ,there was an increase in LSCS in
borderline oligohydramnios than in severe oligohydramnios (90.48% vs.
40.82%). But in our study, there was increased LSCS in severe
oligohydramnios than in borderline oligohydramnios.
 Among those patients who underwent LSCS, 47.1% was for fetal distress
and 23.5% was for severe oligohydramnios, while in the study by Ravikant
et al, 20.52% was for fetal distress and 41.02% was for severe
oligohydramnios.

TABLE COMPARING THE INCIDENCE OF ADVERSE OUTCOMES IN OUR
STUDY WITH SIMILAR STUDIES CONDUCTED IN INDIA
Adverse
outcomes
Jandial et
al(6)
Ravikant et al(7)
---
Our study
Induction of
labour
58%
LSCS for FD
42%
26.52%
47.1%
Preterm delivery
35%
30%
6.7%
IUGR
58%
34.29%
43.3%
NICU admission
16%
25.72%
36.7%
Postnatal death
6%
11.43%
3.3%
Meconium
stained liquor
48%
---
16%
10%
TABLE COMPARING INCIDENCE OF ADVERSE OUTCOMES AMONG
BORDERLINE AND SEVERE OLIGOHYDRAMNIOS GROUPS
ADVERSE OUTCOMES
SEVERE
OLIGOHYDRAMNIOS
BORDERLINE
OLIGOHYDRAMNIOS
Meconium stained liquor
7.1%
12.5%
Preterm delivery
7.1%
7.1%
IUGR
50%
37.5%
LSCS for FD
50%
25%
NICU admission
28.5%
43.75%
Postnatal death
---
6.25%
ACCURACY OF VARIOUS DOPPLER INDICES IN PREDICTING ADVERSE
OUTCOMES
 There was higher incidence of adverse outcomes when the Doppler
velocimetry of the uterine artery, umbilical artery and fetal MCA was
abnormal. In these cases, there was a higher incidence of IUGR and
NICU admission.
 The presence of diastolic notch had the highest specificity and positive
predictive value (100%) among the uterine artery indices, while RI and PI
had good specificity (90%)
 In the umbilical artery, RI, PI and S/D ratio had similar sensitivity,
specificity, positive and negative predictive values of 45%, 100%, 100%
and 47.62% respectively.
 In the MCA, cerebro-placental ratio had the highest sensitivity, specificity,
positive and negative predictive values of 35%, 100%, 100% and 43.68%
with an accuracy of 56.67%.
CONCLUSION
Based on the results and the methodology employed, we have concluded
from our study that :
 AFI < 5cm and AFI 5-8cm in third trimester of pregnancy are both
associated with adverse outcomes in the intra-partum and post-partum
period.
 Severe oligohydramnios has increased incidence of adverse outcomes
than borderline oligohydramnios.
 Among the uterine artery Doppler indices, presence of diastolic notch has
the highest specificity and positive predictive value.
 All three umbilical artery Doppler indices have similar sensitivity,
specificity, positive and negative predictive values with good accuracy in
identifying adverse outcomes.
 Among the fetal MCA Doppler indices, the cerebro-placental ratio has the
highest sensitivity, specificity, positive and negative predictive values
with an accuracy of 56.67 % in identifying adverse outcomes.
 Uterine artery, umbilical artery and fetal MCA Doppler velocimetry are all
associated with increased incidence of adverse outcomes in both severe
and borderline oligohydramnios. An abnormal study of all three vessels
has the highest incidence of IUGR and NICU admission. We also found
that adverse outcomes can still occur even if the Doppler of one vessel is
abnormal and the other two are normal.
 Thus from our study, we conclude that for third trimester oligohydramnios,
Doppler velocimetry of uterine, umbilical and fetal MCA together does
serve as a good indicator of fetuses at risk of developing adverse
outcomes for prompt management.
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