Importance of Doppler study of Umbilical Artery and FoetalMiddle Cerebral Artery in PIH and IUGR

Background: PIH is associated with increased vascular resistance and decreased utero -placental perfusion resulting in an increased incidence of foetal hypoxia and impaired foetalgrowth.The objective of this study was to assess the diagnostic performance of S/D ratio, resistance index(RI), pulsatility index (PI) and cerebro-placental ratio (CPR) in the prediction of adverse perinatal outcome in PIH and IUGR. Objective: is to determine S/D ratio, RI, PI, CPR and asses their diagnostic values in the prediction of adverse perinatal outcome.Material& Methods:50 pregnant patients with PIH and IUGR, beyond 28 weeks of gestation, were prospectively studied at P k das institute of medical college,vaniyamkulamand subjected for Doppler study of the umbilical artery and foetal middle cerebral artery. The abnormality of above parameters was correlated with the major adverse perinatal outcome.Results:Patients with abnormal Doppler parameters had a poor perinatal outcome, compared to those who had normal Doppler study. The cerebro-placental ratios(CPR) had the sensitivity and specificity, positive and negative predictive values of 95%,76%,73%,95% respectively with Kappa value of o .68(good agreement) and p value of .000 which was statistically significant, for the prediction of major adverse perinatal outcome.Conclusions:This study shows that Doppler study of umbilical and foetal middle cerebral artery can reliably predict the neonatal morbidity and helpful in determining the optimal time of delivery in complicated pregnancies. The CPR is more accurate than the independent evaluation of S/D, RI, PI, in identifying foetus with adverse perinatal outcome.

A prospective study of role of doppler in pregnancy and the perinatal outcome

Background: The development of doppler ultrasonographic technology has provided an opportunity to obtain a qualitative and quantitative assessment of maternal and foetal circulation using a non-invasive method. It has been proved by many studies that doppler has a very important role in screening of high-risk pregnancies. Objective of this study was to evaluate the role of colour doppler study in normal and high-risk pregnancy in relation to perinatal outcome.Methods: A prospective study was done including 75 women with high risk pregnancy and 75 normal pregnant women during the period October 2018 to September 2019 in hospitals attached to Bangalore Medical College and Research Institute. Doppler examination was done after recording patients’ history, clinical examination and ultrasound. Results were analysed and conclusions were made.Results: Out of the 22 patients with PIH, 20 patients had abnormal umbilical artery S/D ratio and all 22 had abnormal MCA PI. Out of 12 patients with diabetes, 10 had abnormal umbilical artery S/D ratio. All the patients with IUGR had abnormal umbilical artery S/D ratio and abnormal MCA PI.Conclusions: Colour doppler flow velocimetry done repeatedly can predict adverse foetal events with a great degree of accuracy.

Role of second trimester uterine artery doppler for the prediction of preeclampsia in high risk pregnancy

Background: The uterine artery Doppler has potentials for screening for complications of impaired placentation. The purpose of study was to assess the role of uterine artery color Doppler waveform analysis in second trimester for the prediction of preeclampsia in a high-risk pregnancy between 18-24 weeks of gestation.Methods: 100 women with moderate or high-risk factors for developing preeclampsia reporting to Obstetrics and Gynaecology department of Government Medical College and Hospital, Sector 32, Chandigarh were enrolled for present study. Transabdominal uterine artery doppler measurements was done at 18-24weeks of gestation in these patients. Doppler . The Doppler indices generated automatically from the machine , the Pulsatility Index (PI), Resistance Index (RI) , presence or absence of diastolic notch and S/D Ratio were recorded, and average was calculated.Results: Out of 100 patients there were 46 primigravidas with no additional risk factors, 22 pateints with two or more risk factors and there were no patients who had three or more risk factors in present study population. Preeclampsia is seen more commonly in primigravida and primigravida is considered as moderate risk factor for preeclampsia. It was found that an elevated second trimester uterine artery RI was significantly associated with developing preeclampsia later in pregnancy. The sensitivity and specificity of uterine artery Doppler velocimetry were found to be 84% and 55% respectively. Receiver operator characteristics (ROC) curves were created to demonstrate the prognostic value of RI and PI of uterine artery doppler indices at 18-24 weeks of gestation for the development preeclampsia. In addition, there were statistically significant positive correlations between mean RI of uterine artery doppler study and patients who developed preeclampsia. With a sensitivity of 84.21% it could identify 31% of the cases of preeclampsia at a false positive rate of 44.4%.Conclusions: Uterine artery doppler study can be used as a predictor of moderate strength for preeclampsia.

Risk factors of small-for-gestational-age in severe preeclampsia / 医学研究生学报

Objective Severe preeclampsia (sPE), which is usually complicated by small-for-gestational-age (SGA) and immature labor , remains a leading cause of maternal and neonatal mortality and morbidity. This study was to investigate the risk factors of SGA in sPE. Methods We retrospectively analyzed 100 cases of sPE, 35 with SGA (the case group) and the other 65 without it ( the control group ) .We conducted single-factor analysis on the general characteristics and potential impact factors of the patients , i-dentified the independent risk factors of SGA using the un-conditional stepwise logistic model , and assessed the value of umbilical arter-y S/D ratio and proteinuria ration in the diagnosis of sPE with SGA with the ROC curve . Results Compared with the control group , the case group had more cases of early-onset sPE ( P =0.010 ), earlier gestational and delivery weeks (P<0.001), lower neonatal weight at birth ( P<0 .001 ) , higher rate of admission to and longer stay in the neonatal ICU (P<0.001), and higher incidence of neo-natal complications (P<0.05).The case group also showed signifi-cant increases in comparison with the control in the umbilical artery S/D ratio (2.95 ±0.75 vs 2.31 ±0.47, P<0.05), frequency of S/D ratio ≥95th percentile (22.86% vs 6.15%, P<0.01), and rate of proteinuria ≥5 g/24 h (42.86% vs 20.00%, P<0.05).The S/D ratio ≥95th percentile (OR=6.02, 95%CI:2.32-16.78) and proteinuria≥5 g/24 h (OR=1.65, 95%CI:1.56-3.01) were found to be the risk factors of sPE with SGA.The area under the curve was 0.852 for the combination of S/D ra-tio and proteinuria ration in the diagnosis of sPE with SGA (P<0.05). Conclusion Umbilical artery S/D ratio≥95th percentile and proteinuria ≥5 g/24 h contribute to the early prediction, prevention, and prognosis of sPE, and is valuable for the diagnosis of sPE with SGA.

The Role of Umbilical Artery Doppler in Predicting the Fetal Out Come in Cases of Pregnancy Induced Hypertension

Purpose To determine and compare the diagnostic performance of Doppler sonography of fetal umbilical artery (UA) for prediction of adverse perinatal outcome in suspected intrauterine growth retardation (IUGR) and pre eclampsia. Materials and Methods 100 women with singleton pregnancy between 26 to 30 weeks of gestation were studied in this prospective study over a period of one and half years with color Doppler. UA flow velocity form was studied. In UA systolic/diastolic (S/D) ratio, pulsatility index (PI) and Resistance index (RI) were studied. In UA absent diastolic flow or reversed diastolic flow is noted. Results Out of 50 clinically suspected pregnancy induced hypertension (PIH) cases, 31 (62%) cases show abnormal PI, 40 (80%) cases show abnormal RI values and 45 (90%) cases show abnormal S/D Ratio's. Sensitivity and specificity of the S/D ratio in predicting PIH are 90% and 88% respectively followed by positive and Negative predictive value (PPV & NPV) of 88% and 89% whereas sensitivity, Specificity, PPV and NPV of RI & PI are lower than S/D ratio. This shows that S/D ratio has more Sensitivity, Specificity and Predictive values. Sensitivity of PI value in predicting fetal outcome is 75%. 22% (11 out of 50 cases) cases show absent/reversal of end diastolic velocities, of these four are reversal of end diastolic velocity (RDEV). All four cases of REDV died before 32 weeks of gestation. Absent diastolic flow is seen in 7 cases, 4 cases died and three cases admitted in NICU with severe respiratory distress. Our study shows absent or reversal of end diastolic velocity is more sensitive in predicting adverse fetal outcome. There was no case of eclampsia or maternal death. Conclusion UA flow velocity waveforms abnormality is more predictive for preeclampsia and IUGR. Hence Doppler is a promising tools in prediction of PIH and IUGR

Doppler findings and tocolytic effect of transdermal glyceryl trinitrate and intravenous ritodrine as tocolysis of preterm labor / 대한산부인과학회잡지

OBJECTIVE: This study was conducted to compare the safety and efficacy of transdermal glyceryl trinitrate (GTN) in initial therapy for preterm labor with those of intravenous ritodrine hydrochloride and the effects of tocolytics in uteroplacental circulation, as assessed by uterine artery doppler velocimetry. METHODS: Patients between 24 and 34 weeks gestation with documented preterm labor were randomly assigned to receive transdermal GTN (n=24) or intravenous ritodrine (n=35) as initial tocolytic therapy. Patients in the GTN group were administered 0.2 mg/h released transdermal patch on the pregnant women's abdomen directly. Patient in the ritodrine group were treated 0.025 mg/min as initial dose. The dose increased at 15 minute intervals until uterine contractions were inhibited or side effects become intolerable. The maximum recommended dose was 0.20 mg/min. The main outcome examined were failure of tocolysis, time to uterine quiescence, time gained in utero, and frequency of adverse effects. We obtained both right and left uterine artery doppler velocity waveform before and after tocolytics therapy. The mean values of the right and left uterine artery systolic and diastolic ratio were calculated and used for analysis. RESULTS: There were no significant difference in maternal demographic between the groups. Successful tocolysis was observed in 79.2% in the GTN group, and 85.7% in the ritodrine group (p=0.726). Time to uterine stop contraction was 5.5 +/- 5.3 hr in ritodrine group and 1.1 +/- 0.3 hr in GTN group. There were no different in time to gain in uterus between the two groups. The patient in the ritodrine group had more adverse side effects, mainly maternal tachycardia (p=0.002), chest pain and tremor (p=0.035). There was no significant difference in uterine S/D ratios between the pretherapy and posttherapy GTN group. However, we found statistically significant difference between the pretherapy and 24 hr-posttherapy in ritodrine group. CONCLUSION: Transdermal GTN was effective, safe, and well tolerable tocolytic agent. Patients who received ritodrine hydrochloride were more likely to have adverse effects. We also conclude that GTN do not affect uteroplacental circulations as measured by S/D ratios but ritodrine does. This results suggest that progressively increasing dose of ritodrin and GTN maybe associated with a statistically significant decrease S/D ratios. However, further investigations needs to be performed.

Is Doppler Velocimetry Useful for the Prediction of Uteroplacental Insufficiency? / 대한산부인과학회잡지

This study was designed to investigate a possible role for Doppler velocimetry as apredictor of uteroplacental insufficiency with fetal heart rate(FHR) tracing. From January1994 to through May 1996, we studied 419 high risk pregnant women who underwent Dopplervelocimetry within 1 week of intrapartum cardiotocogram or contraction stress test(CST) after 30 gestational weeks. The presence of a diastolic notch in uterine artery,elevated systolic/diastolic(S/D) ratios in umbilical artery(more than 3.0), or in uterine artery(more than 2.6) were considered abnormal. All of the 419 subjects were performed intrapartumcardiotocogram or CST within 1 week after Doppler veocimetry. Seventeen caseswere associated with persistent late deceleration or positive CST. The sensitivity, specificity,positive predictive value, negative predictive value, and relative risk of umbilical arteryS/D ratio for predicting abnormal FHR tracing were 23.5%(4/17), 89.3%(359/402), 8.5%(4/47), 96.5%(359/372), and 0.97. those of uterine artery S/D ratio and diastolic notch were29.4%(5/17), 92.5%(372/402), 14.3%(5/35), 96.9%(372/384), 1.35 and 35.3%(6/17), 90.3%(363/402), 13.3%(6/45), 97.6%(363/374), 3.88 respectively. The presence of uterine arterydiastolic notch in Doppler velocimetry seems to be a better predictor for abnormal FHRtracing after 30 weeks gestation than are S/D ratios in umbilical or uterine arteries.In conclusion, we can suggest that the presence of diastolic notch in uterine arteryDoppler velocimetry might be useful to predict the uteroplacental insufficiency after 30gestational weeks.

Expression of Adhesion Molecules in Placenta and Correlation with Uterine Artery Doppler Velocimetry in Pregnancy-induced Hypertension / 대한산부인과학회잡지

INTRODUCTION: The pathophysiology of PIH remains unclear. Recently, placental abnormalitiesare stressed as a possible cause of PIH. Abnormal shallow invasion of trophoblasts, confinedto decidua, without involving myometrium is believed to result in reduced uteroplacentalperfusion, endothelial injury, and activation of coagulation cascade system. Integrin, one of theadhesive membrane proteins, is expected to be related to the regulation of trophoblasts invasion. PURPOSE: The purpose of this study is to investigate the expression of adhesion moleculesin placenta and the correlation between uterine artery Doppler findings and integrinexpressions in the placentas of PIH patients. SUBJECTS: Thirty-six cases of severe PIH patients were enrolled in the study with 10number of normal control pregnant women. The integrin subunit expressions withimmunohistochemical staining were observed in floating villi, maternal-side cytotropholbasts, andfetal-side cytotrophoblasts. Uterine artery Doppler study was also performed, and the S/Dratio was evaluated. Abnormal Doppler findings was defined as S/D ratio>or=2.6. RESULTS: Cytoplasmic staining of villi and placental bed cytotrophoblast for theintegrin alpha1 subunit in PIH specimen was weaker than those in normal controls. Theexpression of integrin beta1 subunit was negative for both controls and PIH group. Thepositive cytoplasmic stain was observed among PIH placenta in contrast to normal control inwhich the expression of integrin beta4 subunit was not detected. The expression of alpha v beta3 introphoblast with PIH was positive staining, but not in control group. Uterine artery Dopplervelocimetry was performed in 25 cases with PIH. Trace(+/-) or - staining of integrin alpha1 subunit were observed in 60.0% of abnormal S/D(>or=2.6) group, 20.0% of normal S/Dratio group patients, respectively. Trace or + staining of integrin beta4 subunit were observedin 50.0% of abnormal S/D group and 6.7% of normal S/D group and this is in statisticallysignificant. Trace or + staining of integrin alpha v beta3 subunit were observed 70.0% ofabnormal S/D group and 26.7% of normal S/D group, and this statistically significant. CONCLUSION: In PIH the abnormality in the invasion of cytotrophoblats results inabnormal integrin subunit expression, but it is also correlated to the abnormal uterine arteryDoppler velocimetry which shows a S/D ratio of greater than 2.6. Thus, the uterine arteryDoppler velocimetry reflects abnormal placentation.

The Effects of Epidural Anaesthesia for Caesarean Section on Maternal Uterine and Fetal Umbilical Artery Blood Flow Velocity Waveforms / 대한산부인과학회잡지

OBJECTIVE: To study the effects of maternal epidural anaesthesia on the maternal uterine circulation and the fetal umbilical placental circulation by using Doppler ultrasound techniques. STUDY DESIGN: Twenty-seven patients delivered by elective caesarean section under lumbar epidural anaesthesia were studied. All had a normal pregnancy with no indication of fetal compromise and no indication of maternal disease. Each patient received a 1 litre intravenous crystalloid infusion over 20~30 minutes before an epidural bupivacaine injection. The uterine and fetal umbilical artery velocity waveforms were recorded. And then intravenous cannula and an epidural catheter were inserted. The local anaesthetic agent were injected through the epidural catheter(0.5% bupivacaine 10ml, 20% lidocaine 10 ml). At achieve sensory blockade to the T-4 level after the injection of the anaesthetic agent, the uterine and fetal placental circulation flow velocity-time waveforms were again recorded by using Doppler ultrasound(Multigon 500A, 4 MHz). Significance was tested by means of the paired student t-test. RESULTS: 1. Significant differences were observed between the two groups(Before anaesthesia, S/D ratio of fetal umbilical artery was 2.48+/-0.50. Following anaesthesia, S/D ratio of fetal unbilical artery was 2.24+/-0.40, p < 0.005). 2. Significant differences were observed between the two groups(Before anaesthesia, S/D ratio of maternal uterine artery was 2.29+/-0.41. Following anaesthesia, S/D ratio of maternal uterine artery was 1.95+/-0.25, p < 0.001). CONCLUSION: This study suggests a beneficial fetal effect from the improved maternal uterine perfusion after epidural anesthesia.