Uterine artery Doppler flow velocimetry parameters for predicting gestational trophoblastic neoplasia after complete hydatidiform mole, a prospective cohort study

OBJECTIVES: Doppler ultrasonography can be used to assess neoangiogenesis, a characteristic feature of postmolar gestational trophoblastic neoplasia. However, there is limited information on whether uterine artery Doppler flow velocimetry parameters can predict gestational trophoblastic neoplasia following a complete hydatidiform mole. The purpose of this study was as follows: 1) to compare uterine blood flow before and after complete mole evacuation between women who developed postmolar gestational trophoblastic neoplasia and those who achieved spontaneous remission, 2) to assess the usefulness of uterine Doppler parameters as predictors of postmolar gestational trophoblastic neoplasia and to determine the best parameters and cutoff values for predicting postmolar gestational trophoblastic neoplasia. METHODS: This prospective cohort study included 246 patients with a complete mole who were treated at three different trophoblastic diseases centers between 2013 and 2014. The pulsatility index, resistivity index, and systolic/diastolic ratio were measured by Doppler flow velocimetry before and 4-6 weeks after molar evacuation. Statistical analysis was performed using Wilcoxon’s test, logistic regression, and ROC analysis. RESULTS: No differences in pre- and post-evacuation Doppler measurements were observed in patients who developed postmolar gestational trophoblastic neoplasia. In those with spontaneous remission, the pulsatility index and systolic/diastolic ratio were increased after evacuation. The pre- and post-evacuation pulsatility indices were significantly lower in patients with gestational trophoblastic neoplasia (odds ratio of 13.9-30.5). A pre-evacuation pulsatility index ≤1.38 (77% sensitivity and 82% specificity) and post-evacuation pulsatility index ≤1.77 (79% sensitivity and 86% specificity) were significantly predictive of gestational trophoblastic neoplasia. CONCLUSIONS: Uterine Doppler flow velocimetry measurements, particularly pre- and post-molar evacuation pulsatility indices, can be useful for predicting postmolar gestational trophoblastic neoplasia.

Mecanismo de centralização: da insuficiência placentária à adaptação circulatória fetal: [review] / Brain sparing effect: from placental insufficiency to fetal circulatory adaptation: [review]

A aplicação e o desenvolvimento da doplervelocimetria obstétrica apresentam base para conhecimento da insuficiência placentária e comprovam o comportamento dinâmico da circulação fetal em regime de hipóxia. Na prática clínica, tornou-se quase rotineira a necessidade de se avaliar a hemodinâmica em três territórios vasculares envolvidos na gestação: artérias uterinas, umbilical e cerebral média. Em linhas gerais, a artéria cerebral expressa o balanço entre a oferta de oxigênio nas uterinas e a captação pelas umbilicais. Atualmente, quando este balanço é desfavorável, procura-se ainda conhecer a reserva cardíaca fetal pelo estudo do ducto venoso. Contudo, precisar e interpretar índices de resistência vascular nem sempre é tarefa fácil. O ponto de partida é ter em mente os fundamentos sobre os quais se assenta o papel da doplervelocimetria para a avaliação do bem-estar fetal.

The application and development of obstetric Dopplervelocimetry provide a basis for the investigation of placental insufficiency and demonstrate the dynamic behavior of fetal circulation during hypoxia. In clinical practice, assessing hemodynamics in three vascular regions involved in pregnancy, namely the uterine, umbilical and middle cerebral arteries, has become routine. Roughly, the cerebral artery expresses the balance between uterine artery oxygen supply and umbilical artery oxygen uptake. Currently, when such balance is unfavorable, the fetal cardiac reserve is investigated by assessing the venous duct. However, determining and interpreting vascular resistance indexes is not an easy task. The starting point is to know the physiopathology of placental insufficiency and fetal circulatory adaptation through which Doppler confirmed its role in the assessment of fetal well-being.