Colour doppler friend of fetus


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Colour doppler friend of fetus by Dr Raju R Sahetya

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Colour doppler friend of fetus

  1. 1. Color Doppler in Obstetrics“A true friend of Fetus at Risk” Dr. Raju R Sahetya M.D., D.G.O., D.F.P., F.C.P.S., F.I.C.O.G., OBSTETRICIAN & GYNAECOLOGIST Infertility & Laparoscopic Surgeon Pushpaa Hospital Lokhandwala Complex, Andheri (w), Mumbai, India, drraju RRS
  2. 2. Honorary Hinduja Healthcare – Surgical Hospital, Khar, Mumbai Visiting Hospitals BSES * Mumbadevi * Hiranandani Vice PresidentIndian Society for Prenatal Diagnosis & Fetal Therapy (ISPAT) Member Excecutive Council Mumbai Obstetrics & Gynaecology Society (MOGS) Association of Fellow Gynaecologist (AFG) Assciation of Medical Consultant (AMC) Current Position Held MOGS – PNDT & Academic Cell, FOGSI – Sexual Medicine Committee Editorial Board – ISPAT Int. Journal of Prenatal Diagnosis & AFG Times Rotarian Past President Rotary Club of Bombay Airport RRS
  4. 4. Introduction In a world in which the study of “Life in Utero and Antenatal Diagnosis” of diseases have become realities. Research on pathophysiology of antenatal period has taken on a new importance and relevance RRS
  5. 5. Doppler Velocimetry True Friend - Colour DopplerBased on physical principle of change in frequency of a sound wave when it is reflected by a moving object Described in 1842 by an Austrian physicist and mathematician Johann Christian Doppler. RRS
  6. 6. Color Doppler Imaging Doppler principle is applied to enable vascular flow to be identified in a color-coded display, which indicates the direction of flow Blood flowing towards the ultrasound transducer is conventionally depicted in a band of colors ranging from deep red (low velocity) to bright yellow (high velocity) Flow in direction away from the transducer is indicated by band of colors ranging progressively from deep blue (low velocity) to cyan (high velocity) Doppler imaging illustrates only the direction of flow, color- coded mean velocities and the range of the mean velocities RRS
  7. 7. Fetal circulationThree arterial-venous shunts of fundamentalimportance to the maintenance of fetal oxygen.•Ductus venosus(DV) that carries oxygenated bloodfrom the umbilical vein to IVC & RA•The foramen ovale that allows the passage of bloodfrom right to the left atrium•The Ductus arteriosus that carries blood from thepulmonary artery into aorta, thereby effectivelyby - passing the pulmonary circulation. RRS
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  9. 9. Colour Doppler offers the Obstetrician A noninvasive Easily repeatable Harmless techniquefor studying the Fetus and Placental Circulation RRS
  10. 10. Color Doppler plays a vital role in the diagnosis of fetal cardiac defects. assessment of the hemodynamic responses to fetal hypoxia and anemia. diagnosis of other non-cardiac malformations. RRS
  11. 11. Fetus at Risk Site and viability of early pregnancy Intrauterine growth restriction (IUGR) Fetal Anemia Fetal Anomalies Prediction of Pre-eclampsia Screening for Down Syndrome A long Term Friendship indeed RRS
  12. 12. Colour DopplerSite and viability of early pregnancy Increased vascularity surrounding the gestational sac Increased flow through spiral arteries GS at 6-7 weeks Excellent Visual demonstration of cardiac activity Viability or non-viability on a single scan RRS
  13. 13. Colour DopplerIntrauterine growth restriction (IUGR) Changes in the Arterial Circulation Changes in the Venous Circulation Changes in the Fetal Heart RRS
  14. 14. Pathophysiology of fetal hypoxiaPlacental Insufficiency Decreased in growth Decrease in movements Progressive decompensation Respiratory and metabolic acidosis Renal insufficiency Decreased amniotic fluid volume Myocardial compromise Absent or reversed atrial flow in the DV Late deceleration in the FHR Fetal death RRS
  15. 15. Doppler based management in IUGR Doppler USG provides us valuable information on the utero-placental vascular resistance and, indirectly on blood flow. Analyses of the Doppler waveforms are made by measuring the peak systolic(S) & end diastolic (D) velocities. Three indices are considered related to vascular resistance: S/D, RI, PI. RRS
  16. 16. Doppler indices RRS
  17. 17. Changes in the Arterial Circulation Uterine arteries Doppler The changes in vascular resistance is more marked in uterine artery closer to placental implantation site. Diastolic notching is an index of increased impedance to flow. Abnormal uterine arteries waveforms after 24 wks of gestation are associated with development of preeclampsia, abruption, FGR, morbidity & mortality. RRS
  18. 18. Uterine artery RRS
  19. 19. Changes in the Arterial Circulation Umbilical artery – Signature VesselA direct reflection of the flow within the placentaFirst vessel to be studied when suspecting IUGRcharacteristic saw-tooth appearance of arterial flow inone direction and continuous umbilical venous bloodflow in the other. RRS
  20. 20. The sequence of events of progressive fetalcompromise secondary to placental insufficiency: Increased UA S/D resistance without centralization of flow. Means UA S/D above normal and MCA S/D normal less worrisome Indicates need for closer, frequent fetal surveillance To determine whether or not there is further deterioration. RRS
  21. 21. Absent umbilical artery diastolic flow (AUADF)•UA blood flows only during systole as a result, the oxygensupply to the fetus is decreased and mild metabolic acidosis.•Occurs days to weeks prior to abnormalities found on othermeasures of fetal health - NST, BPP, CST, these indicatingurgent delivery. May not affect long-term neurological outcome RRS
  22. 22. Reversed umbilical artery diastolic flow(RUADF)•“Fetus to placenta” an ominous sign, blood flow is reversedduring diastole, fetuses need to be delivered promptly. At risk of neonatal death and significant morbidity. RRS
  23. 23. Fetal cerebral circulation In mild hypoxia – UA resistance increased, no change in MCA - adaptation of fetal circulation In progressive hypoxia – „Brain sparing effect‟ presence of such compensation suggest a compromised fetus Doppler waveform depicts – increased diastolic flow with decreased pulsatility index RRS
  24. 24. Fetal cerebral circulation Continuing hypoxia – the over stressed fetus loses the brain sparing effect – diastolic flow returns to normal Reflects a terminal de-composition in the setting of acidemia or brain edema Reversal of diastolic flow grave and irreversible fetal neurological outcome RRS
  25. 25. Middle Cerebral Artery RRS
  26. 26. Fetal Aorta The advent of Aortic Isthmus in analyzing early disruption in the cerebral perfusion – New vessel of hope. Severe hypoxia – diastolic flow reverses, correlates with gross acidemia & necrotizing enterocolitis Greater the reverse isthimic flow, lower the IFI higher risk of cerebral damage. RRS
  27. 27. Changes in the Venous Circulation Doppler waveforms – central venous system of fetus reflects physiological status of rt. Ventricle Information on the ventricular preload, myocardial compliance & rt. Ventricular end-diastolic pressureVessels that give invaluable information of adaptation to fetal hypoxia are IVC, DV & UV RRS
  28. 28. Changes in the Venous CirculationDuctus Venosus Doppler DV a continuation of intra abdominal umbilical vein with a narrow inlet and a wider outlet connects to IVC Waveform is M pattern, first and second peak coinciding with ventricular systole & diastole In IUGR-progressive hypoxia and worsening contractility of the ventricles and atria secondary to myocardial ischemia DV shows decrease in forward flow due to increasing pressure gradient in the rt. Atrium. RRS
  29. 29. Changes in the Venous Circulation Ductus Venosus Doppler Tricuspid regurgitation causes reversal of flow in IVC which eventually leads to reversal of flow in the DV Associated with worsening fetal hypoxia and acidemia, preceding abnormities in the fetal heart rate Reverse flow velocity waveform at the DV leads to fetal death. Abnormal UA & MCA waveform, without reverse flow in DV fetal death is not likely RRS
  30. 30. RRS
  31. 31. Umbilical vein In normal pregnancy – monophasic waveform with continuous forward flow Gradually decreases 20th to 38th wks of gestation Last vessels to change its flow pattern in fetal hypoxia In severe cases – reversal of flow in IVC & DV Pulsatile flow pattern begins due to high resistance Increased risk of adverse perinatal outcome RRS
  32. 32. Changes in the Fetal Heart Involve preload, after load, ventricular compliance and myocardial contractility Abnormalities in the right diastolic followed by right systolic indices followed by left diastolic & systolic cardiac indices Left systolic function last to become abnormal ensures an adequate left ventricular output supply to cerebral and coronary circulation RRS
  33. 33. Changes in the Fetal Heart Changes in both sides Preload is reduced at both atrioventricular valves due to hypovolemia & decreased filling Reduced myocardial contractility Ventricular ejection force is decreased Shorter time to delivery, non-reassuring fetal heart tracing and a lower pH ( acidosis) at birth. Values validitates severity of fetal compromise RRS
  34. 34. RRS
  35. 35. Changing trends in Doppler In 21st century assessment of IUGR Fetuses Identify pregnancy at risk of IUGR and / or prevent decompensation, hence doppler shifting, from curative to preventive medicine. 12 to 16 wks screening of Uterine artery in high risk can identify accurately a subset of women who are destined for major complications attributed to placental diseases. New vessels giving new hope – Aortic Isthmus velocity waveform (Isthimic flow index-IFI) becomes abnormal at earlier stage of fetal compromise than DV. RRS
  36. 36. Colour Doppler in Fetal AnemiaMiddle Cerebral Artery peak systolic flow velocity (MCA –PSV)serves as a useful measure of fetal anemia severe enough torequire IUT.Almost 70% of cordocentesis can be avoided.Hence reduces the potential risks of pregnancy loss RRS
  37. 37. Middle Cerebral ArteryFlow velocity waveform in the fetal middle cerebral artery in a severely anemic fetus at 22 weeks (left) Normal fetus (right). In fetal anemia, blood velocity is increased RRS
  38. 38. Color Doppler in Fetal Anomalies Fetal cardiac anomalies, anomalies of vascular origin Greatly enhanced, diagnosed and characterized much better Changes in the flow pattern are demonstrated Transposition of the great vessels (TGV) Total anomalous pulmonary vasculature (TAPV) RRS
  39. 39. Color DopplerDown Syndrome ScreeningFetuses with Down syndrome exhibit changes in thefetal circulation & echocardiography @ 11 to 14 wksThe normally forward flow in the fetal ductusvenosus is absent or reversed during atrialcontraction in Down syndrome fetuses An independent marker. RRS
  40. 40. Doppler ultrasound for the fetal assessment in high-riskpregnancies(Cochrane Review). In: The Cochrane Library, 1999.Neilson JP and Alfirevic Z 11 Studies Included In Analysis  Trudinger et al 1987 Almstrom et al 1992  McParland et al 1988 Biljan et al 1992  Tyrrell et al 1990 Johnstone et al 1993  Hofmeyr et al 1991 Pattison et al 1994  Newham et al 1991 Nienhuis et al 1997  Burke et al 1992 RRS
  41. 41. Doppler ultrasound for the fetal assessment in high-risk pregnancies Meta analysis Nearly 7000 patients were included The trials compared no Doppler ultrasound to Doppler ultrasound in high-risk pregnancy (hypertension or presumed impaired fetal growth) RRS
  42. 42. Doppler ultrasound for the fetal assessment inhigh-risk pregnancies Main results A reduction in perinatal deaths. Fewer inductions of labour . Fewer admissions to hospital . no report of adverse effects . No difference was found for fetal distress in labour . No difference in caesarean delivery . RRS
  43. 43. Conclusion Placental insufficiency highly associated with perinatal mortality and morbidity. Uterine artery important role in predicting PIH & IUGR at 20-24 wks. Reverse flow in the umbilical artery, along with pathologic waveform in the venous system are the best predictor of severe fetal distress. RRS
  44. 44. Conclusion Role of Doppler has shifted from curative to preventive one with truly informed and meaningful brain oriented fetal care. Delivery of the sick fetus can be appropriately timed to prevent associated complications RRS
  45. 45. Colour Doppler in Obstetrics “A True Friend of Fetus at Risk” RRS