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COLOR DOPPLER IN FETAL
GROWTH RESTRICTION AND
       HYPOXIA

       narendra malhotra
        jaideep malhotra
       neharika malhotra



     www.malhotrahospitals.com
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
PERSPECTIVE

   EXCLUDE FETAL ANOMALIES
   EVALUATE FETAL SIZE
   QUANTIFY LIQUOR AMNII
   EVALUATE BIOPHYSICAL PARAMETERS
   ASSESS PLACENTA, CORD & CERVIX
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
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
REQUIREMENTS
HIGH RESOLUTION GRAY SCALE 2D IMAGE ( 2D US )

SUPERIMPOSED COLOR FLOW MAP ( CFM )

DOPPLER SPECTRAL ANALYSIS ( dD )
COLOR DOPPER IN IUGR



METHODOLOGY
NORMAL FETAL CICULATION
HYPOXIA-REDISTRIBUTION MECHANISM IN IUGR
MANAGEMENT STATEGIES
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°.
Principles of Color Doppler




Color Doppler         Power Doppler
Principles of Color Doppler
Quantitative analysis
  Doppler indices
The Supply Line to the Human Fetus




                                                                  Placenta
Cuningham FG, MacDonald PC, Leveno K, Gant NF, Gilstrap LC II Williams Obstetrics 1993
Small for Gestational Age
            Environmental     Infection/
                            Inflammation


  Genetic                              Endocrine


                                            Maternal
Nutritional


Placental                                  Unknown
Umbilical
vessels           Chorionic      Chorionic                  Amnion
                   vessels         plate




                                                    Placental
                                 Spiral              septum
 Uteroplacental          Basal   artery
     veins               plate


                                          Sadler TW Lagman’s Medical Embryology 1990
NORMAL FETAL CIRCULATION
FETAL HYPOXIA-ACIDOSIS


 AORTIC BODY CHEMORECEPTOR
         STIMULATION


REFLEX REDISTRIBUTION OF FETAL
       CARDIAC OUTPUT
REFLEX REDISTRIBUTION OF
        FETAL CARDIAC OUTPUT


    DECREASED FLOW                INCREASED FLOW
   KIDNEYS          (OLIGURIA)      BRAIN
                 (OLIGOAMNIOS)
   LUNGS                 (RDS)      HEART
   GUT                   (NEC)
   LIVER/MUSCLE         (IUGR)
    BODY FAT/                        ADRENALS
    GLYCOGEN STORES
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.
C O L O R  D O P P L E R  I N  F E T A L  H Y P O X I A
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
UTERINE ARTERIES
REFLECTS : TROPHOBLASTIC INVASION


END POINTS :
   ELEVATED RESISTIVE INDICES (>2SD)
   PERSISTENT DIASTOLIC NOTCHING
   PRESENCE OF SYSTOLIC NOTCHING
   MAJOR LEFT TO RIGHT VARIATION
SITE:Uterine Artery



      Empty Bladder
       Inside down




Utero placental circulation
NORMAL & ABNORMAL
WAVEFORM IN ADVANCED PREG




                    Diastolic Notch
               (irrespective of the RI)
Uterine artery




  Screening test
Abnormal Uterine Artery
                       Doppler Velocimetry




Normal uterine artery Doppler       Abnormal uterine artery Doppler
Utero placental circulation




Conversion of spiral artery into utero
placental vessel
                                            Brosens et al
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
Uterine artery
   At 24 weeks
     No Dichrotic Notch
     PI < 1.2




    Routine Screening
         Pre eclampsia & it’s severity can be predicted
         Monitoring of fetus
Uteroplacental circulation


           Normal
                      Uterine Artery Abnormal
UMBILICAL ARTERIES
REFLECTS : PLACENTAL OBLITERATION




END POINTS :
   ABSENT END DIASTOLIC FLOW
   REVERSED END DIASTOLIC FLOW
NORMAL & ABNORMAL WAVEFORM
   IN ADVANCED PREGNANCY
UMBILICAL ARTERY


Advancing gestation
   Progressive rise in the end-
    diastolic velocity
   Decrease in the pulsatility index.
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
   2nd and 3rd it is around 0.5       end, placental end or in
                                      between – no difference
Umbilical Artery flow What does it
            tell us ??



   First sign of hypoxia & growth retardation
Utero-placental
            circulation
 Umbilical
 artery
 progressive
   maturation of
   the placenta
   and increase in
   the number of
   tertiary stem
   villi.
Umbilical Artery
 Changes  in
 umbilical artery
 waveform are
 evident only
 when 60% of
 Placental blood
 flow is
 obliterated
Normal Umbilical Artery

      1º trimester
      Absent Diastolic Flow




      early 2ºtrimester
      Low Diastolic Flow




      late 2º and 3º
      trimester
      Resistance further
      reduce, more diastolic
      flow
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
Utero placental circulation

  Normal                               Abnormal
                    Umbilical Artery
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
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
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
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
MIDDLE CEREBRAL ARTERIES




    REFLECTS : CEREBRAL FLOW

END POINTS : RISING PI AFTER A NADIR
SITE
NORMAL & ABNORMAL WAVEFORM
Middle cerebral artery




The blood velocity increases, PI decreases with advancing
gestation
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.
DESCENDING ABDOMINAL AORTA




REFLECTS   : FLOW TO THE ABDOMINAL
             VISCERA AND LOWER LIMBS
END POINTS : PULSATILITY INDEX>6
SITE
NORMAL WAVEFORM
FETAL AORTA
   Reflects cardiac output& per. Resistance.
   Diastolic velocities present during 2nd &3rd
    trimesters , PI remains constant.
   Summation of blood flows to flow in
    kidneys, abdominal organs, lower limbs and
    placenta.
   Approximately 50% of flow >>umb.artery.
FETAL VENOUS
             CIRCULATION

   INFERIOR VENA CAVA      FORAMEN OVALE

RIGHT HEPATIC VEIN
  MIDDLE HEPATIC VEIN       LEFT HEPATIC VEIN
                        DUCTUS VENOSUS
PORTAL VEIN




                                UMBILICAL VEIN
DUCTUS VENOSUS


REFLECTS     : ACIDOSIS


END POINTS   : ABSENT FORWARD
              FLOW
              IN DIASTOLE
SITE DUCTUS VENOSUS
Anatomy
Ductus Venosus Flow Waveform




                       Hecher, Circulation, 1995
Ductus Venosus Flow

   Modulated by:
     DV diameter

     Portal venous resistance

     Increased Hct       increased DV shunt.
     Humoral factors:

        PGs

        NO

        Adrenergic stimulus
NORMAL & ABNORMAL WAVEFORM
UMBILICAL VEIN




REFLECTS : MYOCARDIAL FUNCTION

END POINTS : DOUBLE PULSATILE PATTERN
SITE
C O L O R  D O P P L E R  I N  F E T A L  H Y P O X I A
ABNORMAL WAVEFORM
Cardiac Function ?


         RV
    LV
Pulmonary
             Right                                     Valve
             Coronary
             Artery


Right                                                  Pulmonary
Ventricle                                              artery
              Aorta




              Left Atrium

                                                      Left
                                                      Coronary
                                                      Artery

            Gembruch & Baschat. Ultrasound Obstet Gynecol 1996;7:10-15
C O L O R  D O P P L E R  I N  F E T A L  H Y P O X I A
C O L O R  D O P P L E R  I N  F E T A L  H Y P O X I A
3 D STIC AND INVERSION MODE ANALYSIS
Can a fetus have a heart
        attack ?
DECOMPENSATION
Fetus
   Hypoxic fetus
       Hypoxic Hypoxia
          PIH
          Post maturity

          Severe Maternal Anemia

          Sickle cell anemia

       Anemic Hypoxia
          Immune Hydrops
          Non Immune Hydrops

       Ischemic Hypoxia (Acute)
          Cord Compression
          Accidental Hemorrhage

   Fetus of Diabetic Mother
Additional ultrasound findings in
                 identifying IUGR
• Doppler flow profiles
     – elevated umbilical artery S/D ratio
     – elevated uterine artery S/D ratio
     – persistent diastolic notching in the uterine
     artery
     – decreased middle cerebral artery S/D ratio
Redistribution During Fetal Hypoxemia
UMBILICAL ARTERY-High resistance




       AEDF




REDF-PRETERMINAL EVENT
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 .
FETAL AORTA


       AEDF-Per. Vasoconst.-
        redistribution to MCA.

       Acidemia.

       Necrotising enterocolitis
CARDIAC FAILURE -VENOUS BLOOD FLOW

                    Retrograde flow in IVC
                     , DV with atrial
                     contraction
                    UV pulsations
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
stage I

   an abnormal umbilical artery or middle cerebral artery
    pulsatility index;
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)
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.
Each stage divided in A & B

   A   is AMNIOTIC FLUID INDEX <5

   B   is AMNIOTIC FLUID INDEX OF >5
   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.
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.
Assessment of IUGR Fetus

   Biometry
   Fetal assessment for malformation
   AF
   Fetal Activity (Biophysical Profile)
   Color Doppler
IUGR Fetal surveillance

   Fetal heart rate monitoring
   Biophysical profile
   NST
   CST
   VAST
   Fetal blood sampling
   Color Doppler Study
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
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
How to Judge Degree of Hypoxia?




         Fetal arterial doppler
             Cut off Line
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
Pulsatile Umbilical vein Flow
MCA flow
PI
     More than 1.45 before term
     Fall down to 1
     If less than 1 peak of
     redistribution
How to Judge degree of Acidemia?

         Fetal Venous doppler
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
RA

                   RV


                        HV
              DV




         RA

                   RV


                    HV
              DV




Growth Retardation
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
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.
Markers For Fetal illness


   AFI        Chronic Marker
   NST
   FT         Acute Markers
   FM
   FBM
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
Oligohydramnios Indicates



Abnormal BPP independent of other variables
 because of a risk of cord complications and
 fetal death.
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.
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
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
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
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
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
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
THANK YOU
C O L O R  D O P P L E R  I N  F E T A L  H Y P O X I A
Thanks You for Attention

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C O L O R D O P P L E R I N F E T A L H Y P O X I A

  • 1. COLOR DOPPLER IN FETAL GROWTH RESTRICTION AND HYPOXIA narendra malhotra jaideep malhotra neharika malhotra www.malhotrahospitals.com
  • 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
  • 3. PERSPECTIVE  EXCLUDE FETAL ANOMALIES  EVALUATE FETAL SIZE  QUANTIFY LIQUOR AMNII  EVALUATE BIOPHYSICAL PARAMETERS  ASSESS PLACENTA, CORD & CERVIX
  • 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
  • 6. REQUIREMENTS HIGH RESOLUTION GRAY SCALE 2D IMAGE ( 2D US ) SUPERIMPOSED COLOR FLOW MAP ( CFM ) DOPPLER SPECTRAL ANALYSIS ( dD )
  • 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°.
  • 9. Principles of Color Doppler Color Doppler Power Doppler
  • 11. Quantitative analysis Doppler indices
  • 12. The Supply Line to the Human Fetus Placenta Cuningham FG, MacDonald PC, Leveno K, Gant NF, Gilstrap LC II Williams Obstetrics 1993
  • 13. Small for Gestational Age Environmental Infection/ Inflammation Genetic Endocrine Maternal Nutritional Placental Unknown
  • 14. Umbilical vessels Chorionic Chorionic Amnion vessels plate Placental Spiral septum Uteroplacental Basal artery veins plate Sadler TW Lagman’s Medical Embryology 1990
  • 16. FETAL HYPOXIA-ACIDOSIS AORTIC BODY CHEMORECEPTOR STIMULATION REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT
  • 17. REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT DECREASED FLOW INCREASED FLOW  KIDNEYS (OLIGURIA)  BRAIN (OLIGOAMNIOS)  LUNGS (RDS)  HEART  GUT (NEC)  LIVER/MUSCLE (IUGR) BODY FAT/  ADRENALS GLYCOGEN STORES
  • 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.
  • 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
  • 22. SITE:Uterine Artery Empty Bladder Inside down Utero placental circulation
  • 23. NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREG Diastolic Notch (irrespective of the RI)
  • 24. Uterine artery Screening test
  • 25. Abnormal Uterine Artery Doppler Velocimetry Normal uterine artery Doppler Abnormal uterine artery Doppler
  • 26. Utero placental circulation Conversion of spiral artery into utero placental vessel Brosens et al
  • 27. 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
  • 28. Uterine artery  At 24 weeks  No Dichrotic Notch  PI < 1.2  Routine Screening  Pre eclampsia & it’s severity can be predicted  Monitoring of fetus
  • 29. Uteroplacental circulation Normal Uterine Artery Abnormal
  • 30. UMBILICAL ARTERIES REFLECTS : PLACENTAL OBLITERATION END POINTS :  ABSENT END DIASTOLIC FLOW  REVERSED END DIASTOLIC FLOW
  • 31. NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREGNANCY
  • 32. UMBILICAL ARTERY Advancing gestation  Progressive rise in the end- diastolic velocity  Decrease in the pulsatility index.
  • 33. 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 2nd and 3rd it is around 0.5 end, placental end or in between – no difference
  • 34. Umbilical Artery flow What does it tell us ?? First sign of hypoxia & growth retardation
  • 35. Utero-placental circulation  Umbilical artery progressive maturation of the placenta and increase in the number of tertiary stem villi.
  • 36. Umbilical Artery  Changes in umbilical artery waveform are evident only when 60% of Placental blood flow is obliterated
  • 37. Normal Umbilical Artery 1º trimester Absent Diastolic Flow early 2ºtrimester Low Diastolic Flow late 2º and 3º trimester Resistance further reduce, more diastolic flow
  • 38. 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. Utero placental circulation Normal Abnormal Umbilical Artery
  • 40. 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
  • 41. 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
  • 42. 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
  • 43. 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
  • 44. MIDDLE CEREBRAL ARTERIES REFLECTS : CEREBRAL FLOW END POINTS : RISING PI AFTER A NADIR
  • 45. SITE
  • 46. NORMAL & ABNORMAL WAVEFORM
  • 47. Middle cerebral artery The blood velocity increases, PI decreases with advancing gestation
  • 48. 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.
  • 49. DESCENDING ABDOMINAL AORTA REFLECTS : FLOW TO THE ABDOMINAL VISCERA AND LOWER LIMBS END POINTS : PULSATILITY INDEX>6
  • 50. SITE
  • 52. FETAL AORTA  Reflects cardiac output& per. Resistance.  Diastolic velocities present during 2nd &3rd trimesters , PI remains constant.  Summation of blood flows to flow in kidneys, abdominal organs, lower limbs and placenta.  Approximately 50% of flow >>umb.artery.
  • 53. FETAL VENOUS CIRCULATION INFERIOR VENA CAVA FORAMEN OVALE RIGHT HEPATIC VEIN MIDDLE HEPATIC VEIN LEFT HEPATIC VEIN DUCTUS VENOSUS PORTAL VEIN UMBILICAL VEIN
  • 54. DUCTUS VENOSUS REFLECTS : ACIDOSIS END POINTS : ABSENT FORWARD FLOW IN DIASTOLE
  • 57. Ductus Venosus Flow Waveform Hecher, Circulation, 1995
  • 58. Ductus Venosus Flow  Modulated by:  DV diameter  Portal venous resistance  Increased Hct increased DV shunt.  Humoral factors:  PGs  NO  Adrenergic stimulus
  • 59. NORMAL & ABNORMAL WAVEFORM
  • 60. UMBILICAL VEIN REFLECTS : MYOCARDIAL FUNCTION END POINTS : DOUBLE PULSATILE PATTERN
  • 61. SITE
  • 65. Pulmonary Right Valve Coronary Artery Right Pulmonary Ventricle artery Aorta Left Atrium Left Coronary Artery Gembruch & Baschat. Ultrasound Obstet Gynecol 1996;7:10-15
  • 68. 3 D STIC AND INVERSION MODE ANALYSIS
  • 69. Can a fetus have a heart attack ?
  • 71. Fetus  Hypoxic fetus  Hypoxic Hypoxia  PIH  Post maturity  Severe Maternal Anemia  Sickle cell anemia  Anemic Hypoxia  Immune Hydrops  Non Immune Hydrops  Ischemic Hypoxia (Acute)  Cord Compression  Accidental Hemorrhage  Fetus of Diabetic Mother
  • 72. Additional ultrasound findings in identifying IUGR • Doppler flow profiles – elevated umbilical artery S/D ratio – elevated uterine artery S/D ratio – persistent diastolic notching in the uterine artery – decreased middle cerebral artery S/D ratio
  • 74. UMBILICAL ARTERY-High resistance AEDF REDF-PRETERMINAL EVENT
  • 75. 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 .
  • 76. FETAL AORTA  AEDF-Per. Vasoconst.- redistribution to MCA.  Acidemia.  Necrotising enterocolitis
  • 77. CARDIAC FAILURE -VENOUS BLOOD FLOW  Retrograde flow in IVC , DV with atrial contraction  UV pulsations
  • 78. 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
  • 79. stage I  an abnormal umbilical artery or middle cerebral artery pulsatility index;
  • 80. 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)
  • 81. 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.
  • 82. Each stage divided in A & B  A is AMNIOTIC FLUID INDEX <5  B is AMNIOTIC FLUID INDEX OF >5
  • 83. 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.
  • 84. 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.
  • 85. Assessment of IUGR Fetus  Biometry  Fetal assessment for malformation  AF  Fetal Activity (Biophysical Profile)  Color Doppler
  • 86. IUGR Fetal surveillance  Fetal heart rate monitoring  Biophysical profile  NST  CST  VAST  Fetal blood sampling  Color Doppler Study
  • 87. 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
  • 88. 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
  • 89. How to Judge Degree of Hypoxia? Fetal arterial doppler Cut off Line
  • 90. 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
  • 92. MCA flow PI More than 1.45 before term Fall down to 1 If less than 1 peak of redistribution
  • 93. How to Judge degree of Acidemia? Fetal Venous doppler
  • 94. 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
  • 95. RA RV HV DV RA RV HV DV Growth Retardation
  • 96. 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
  • 97. 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.
  • 98. Markers For Fetal illness  AFI Chronic Marker  NST  FT Acute Markers  FM  FBM
  • 99. 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
  • 100. Oligohydramnios Indicates Abnormal BPP independent of other variables because of a risk of cord complications and fetal death.
  • 101. 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.
  • 102. 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
  • 103. 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
  • 104. 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
  • 105. 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
  • 106. 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
  • 107. 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
  • 110. Thanks You for Attention