Doppler in Obstetrics
Farhan Hanif,MD
Maternal Fetal Medicine
• Doppler assessment of the placental and
fetal circulation is important tool screening
for adverse pregnany outcomes
MCA
Arch of the aorta
Aortic isthmus
Coronary arteries
Foramen ovale
Tricuspid valve
Pulmonary artery
Mitral valve
Inferior vena cava
Hepatic/Splenic
Ductus venosus
Umbilicus
Umbilical vein
Common iliac artery
Common iliac artery
Umbilical arteries
Br Heart J 1994;71:232-237.
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Doppler in IUGR
•
•
•
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•
EFW<10th %ile
EFW <2SD above the mean
EFW <5th %ile
AC <5th %ile
ACOG defines IUGR as EFW <10thile
Compensatory Mechanisms
Fetal Hypoxemiaplacental insufficiency
UA
Blood flow Redistribution
Brain, heart, adrenal Gland
Lung, kidney, bowel
MCA PI
AF
Echogenic
Bowel
Decompensation
Myocardial dysfunction
Pressure in Rt Atrium /
Dilatation of DV
Abnormal Venous
Doppler
Fetal Hypoxemia / Acidosis
Abnormalities in
Central Control of FHR
“ANS” or
Direct Myocardial Depression
Variability
Baseline
Deceleration
Umbilical artery
Abnormal Umbilical vein
Abnormal Umbilical vein
Abnormal Umbilical artery
MCA waveforms
A = Normal
Normal
Brain Sparing
B = “Brain sparing effect”
MCA Doppler In Anemia
• In Anemic fetuses, the PSV will inrease.
• Obtaining PSV at 0 degrees angle is
important in anemic fetuses.
• Increase False positive rate after 34
weeks
AGA
IUGR
a
IUGR
S D
Role of Ductus Venosus
45
40
35
30
25
20
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DV Normal
UA A/REDF
DV Abn
DV A/REDF
Groups
Baschat et al ultrasound obstet gynecol 2004
Temporal Sequence of
Cardiovascular
changes in
IUGR fetuses
Ferrazi et al. US Obstet Gynecol 2002; 19: 140-6
Doppler Indices and outcomes
• In complicated pregnancies abnormal
Doppler indices are powerful predictors of
adverse perinatal
outcome;
Low
Apgar score
Nonreassuring fetal status
Low
pH
Presence
of thick meconium
Admission to
NICU
Doppler Indices and outcomes
• Reduce perinatal death and
unnecessary induction of labor in the
preterm growth restricted fetus.
• A meta-analysis use of Doppler
ultrasonography reduced the odds of
perinatal death by 38 percent (95%
CI 15-55)
Alfirevic Z et al Am J Obstet Gynecol 199
Umbilical Artery
• Absence or reversal of end-diastolic
flow in the umbilical artery is
suggestive of poor fetal condition,
whereas normal or slightly decreased
umbilical Doppler flow is rarely
associated with significant morbidity
Ott WJ J Ultrasound Med 2000
IUGR
Doppler UA and MCA
If Normal
Repeat Doppler in 1-2 weeks
If normal
Serial Growth Scan 4 weeks interval
Doppler UA and MCA every 1-2 weeks
Evaluate MCA at term
?APFS
Consider Delivery at 39 weeks
Abnormal Doppler UA and MCA
Present
DV Normal
EDF
Present
Growth Scan 2-4 wks
Weekly UA, MCA,+/DV
Admit
Steroids
NST q shift and daily BPP
Absent/Reverse
DV EDF
Ab/Reverse
Admit
Steroids
Continuous monitoring
May follow as outpatient
BMZ,APFS
Deliver at 32-34wks
Abnormal APFS
Consider Delivery at 35-37 weeks
?Timing of Delivery
Absent or Reversed Flow in the Ductus Venosus
EGA
>30weeks
Deliver
<30weeks
Continuous Monitoring
Daily BPP
Daily Doppler
Evaluate AoA, Valves
Deliver for Abnormal BPP,FHT
?Reversed AoA,E:A Ratio
Doppler in AGA Fetuses
• Routine screening with dopplers in AGA fetuses
is controversial
• However, abnormal UA identifies the fetuses at
risk in uncomplicated pregnancies as
DM
Ch
HTN
SLE
Maternal autoimmune
Twins
Postterm
Uterine Artery Doppler
Uterine Artery Doppler
First trimester
Early 2nd Trimester
Late 2nd trimester
Prediction of PE
Outcome
Sensitivity
Specificity
NPV
PE
78
95
99
IUGR <10
23
95
96
IUGR <3
36
96
92
Prevention
Study
n
Condition
Outcome
McParland et al
100
PE
ASA 2%, P 19%
Bower et al
60
Severe PE
ASA 13%, P 38%
Morris et al
102
PE
ASA 8%, P 14% (NS)
Uterine Artery in 1st trimester
7797 women with singleton pregnancies at 11 to 13 weeks.
In 34 women , at < 34 weeks.
At a 5% FPR;
The sensitivity 94.1 percent
The specificity was 94.3 percent
Doppler in first Trimester
• Increases the sensitivity of first trimester
screening and decreases the false postivie
rate
• DV reversed flow in DV in first trimester is
a risk factor for CHD even in the presence
of normal NT
• Can be used as a part of risk calculation
for stillbirth
• CAN be used as a tool to