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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

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lecture delivered at MANILA AOFOG USH WORKSHOP

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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. 1. COLOR DOPPLER IN FETALGROWTH RESTRICTION AND HYPOXIA narendra malhotra jaideep malhotra neharika malhotra www.malhotrahospitals.com
  2. 2. IMPORTANCETHE ACCURACY OF DOPPLER VELOCIMETRY INCONJUNCTION WITH 2D ULTRASOUND ANDCOLOR FLOW MAPPING IS NOW REGARDED ASAN INDISPENSABLE COMPONENT OF APREGNANCY SONOGRAM
  3. 3. PERSPECTIVE EXCLUDE FETAL ANOMALIES EVALUATE FETAL SIZE QUANTIFY LIQUOR AMNII EVALUATE BIOPHYSICAL PARAMETERS ASSESS PLACENTA, CORD & CERVIX
  4. 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. 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. 6. REQUIREMENTSHIGH RESOLUTION GRAY SCALE 2D IMAGE ( 2D US )SUPERIMPOSED COLOR FLOW MAP ( CFM )DOPPLER SPECTRAL ANALYSIS ( dD )
  7. 7. COLOR DOPPER IN IUGRMETHODOLOGYNORMAL FETAL CICULATIONHYPOXIA-REDISTRIBUTION MECHANISM IN IUGRMANAGEMENT STATEGIES
  8. 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. 9. Principles of Color DopplerColor Doppler Power Doppler
  10. 10. Principles of Color Doppler
  11. 11. Quantitative analysis Doppler indices
  12. 12. The Supply Line to the Human Fetus PlacentaCuningham FG, MacDonald PC, Leveno K, Gant NF, Gilstrap LC II Williams Obstetrics 1993
  13. 13. Small for Gestational Age Environmental Infection/ Inflammation Genetic Endocrine MaternalNutritionalPlacental Unknown
  14. 14. Umbilicalvessels Chorionic Chorionic Amnion vessels plate Placental Spiral septum Uteroplacental Basal artery veins plate Sadler TW Lagman’s Medical Embryology 1990
  15. 15. NORMAL FETAL CIRCULATION
  16. 16. FETAL HYPOXIA-ACIDOSIS AORTIC BODY CHEMORECEPTOR STIMULATIONREFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT
  17. 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. 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.
  19. 19. Doppler vessels to be studied MATERNAL SIDEUterine artery PLACENTAL SIDEUmbilical a FETAL SIDEArterial:mca,fetal a,renal and othersVenous:ductus,hepatic,umbilicalFetal echocardiography
  20. 20. UTERINE ARTERIESREFLECTS : TROPHOBLASTIC INVASIONEND POINTS : ELEVATED RESISTIVE INDICES (>2SD) PERSISTENT DIASTOLIC NOTCHING PRESENCE OF SYSTOLIC NOTCHING MAJOR LEFT TO RIGHT VARIATION
  21. 21. SITE:Uterine Artery Empty Bladder Inside downUtero placental circulation
  22. 22. NORMAL & ABNORMALWAVEFORM IN ADVANCED PREG Diastolic Notch (irrespective of the RI)
  23. 23. Uterine artery Screening test
  24. 24. Abnormal Uterine Artery Doppler VelocimetryNormal uterine artery Doppler Abnormal uterine artery Doppler
  25. 25. Utero placental circulationConversion of spiral artery into uteroplacental vessel Brosens et al
  26. 26. 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
  27. 27. Uterine artery At 24 weeks  No Dichrotic Notch  PI < 1.2 Routine Screening  Pre eclampsia & it’s severity can be predicted  Monitoring of fetus
  28. 28. Uteroplacental circulation Normal Uterine Artery Abnormal
  29. 29. UMBILICAL ARTERIESREFLECTS : PLACENTAL OBLITERATIONEND POINTS : ABSENT END DIASTOLIC FLOW REVERSED END DIASTOLIC FLOW
  30. 30. NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREGNANCY
  31. 31. UMBILICAL ARTERYAdvancing gestation Progressive rise in the end- diastolic velocity Decrease in the pulsatility index.
  32. 32. Umbilical artery Flow S/D ratio 2-3 in 2nd & 3rdtrimester PI1.5 – 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
  33. 33. Umbilical Artery flow What does it tell us ?? First sign of hypoxia & growth retardation
  34. 34. Utero-placental circulation Umbilical artery progressive maturation of the placenta and increase in the number of tertiary stem villi.
  35. 35. Umbilical Artery Changes in umbilical artery waveform are evident only when 60% of Placental blood flow is obliterated
  36. 36. Normal Umbilical Artery 1º trimester Absent Diastolic Flow early 2ºtrimester Low Diastolic Flow late 2º and 3º trimester Resistance further reduce, more diastolic flow
  37. 37. 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
  38. 38. Utero placental circulation Normal Abnormal Umbilical Artery
  39. 39. 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
  40. 40. N = 459 Umbilical ArteryFlow 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
  41. 41. 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
  42. 42. 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
  43. 43. MIDDLE CEREBRAL ARTERIES REFLECTS : CEREBRAL FLOWEND POINTS : RISING PI AFTER A NADIR
  44. 44. SITE
  45. 45. NORMAL & ABNORMAL WAVEFORM
  46. 46. Middle cerebral arteryThe blood velocity increases, PI decreases with advancinggestation
  47. 47. Middle cerebral artery DecompensationBrain sparing effect may be transientOverstressed fetus can lose the brain sparing effect.Disappearance of brain sparing effect - very criticalevent for the fetus- precedes fetal death.MCA may have tremendous implication for determiningthe proper timing of delivery.
  48. 48. DESCENDING ABDOMINAL AORTAREFLECTS : FLOW TO THE ABDOMINAL VISCERA AND LOWER LIMBSEND POINTS : PULSATILITY INDEX>6
  49. 49. SITE
  50. 50. NORMAL WAVEFORM
  51. 51. 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.
  52. 52. FETAL VENOUS CIRCULATION INFERIOR VENA CAVA FORAMEN OVALERIGHT HEPATIC VEIN MIDDLE HEPATIC VEIN LEFT HEPATIC VEIN DUCTUS VENOSUSPORTAL VEIN UMBILICAL VEIN
  53. 53. DUCTUS VENOSUSREFLECTS : ACIDOSISEND POINTS : ABSENT FORWARD FLOW IN DIASTOLE
  54. 54. SITE DUCTUS VENOSUS
  55. 55. Anatomy
  56. 56. Ductus Venosus Flow Waveform Hecher, Circulation, 1995
  57. 57. Ductus Venosus Flow Modulated by:  DV diameter  Portal venous resistance  Increased Hct increased DV shunt.  Humoral factors:  PGs  NO  Adrenergic stimulus
  58. 58. NORMAL & ABNORMAL WAVEFORM
  59. 59. UMBILICAL VEINREFLECTS : MYOCARDIAL FUNCTIONEND POINTS : DOUBLE PULSATILE PATTERN
  60. 60. SITE
  61. 61. ABNORMAL WAVEFORM
  62. 62. Cardiac Function ? RV LV
  63. 63. Pulmonary Right Valve Coronary ArteryRight PulmonaryVentricle artery Aorta Left Atrium Left Coronary Artery Gembruch & Baschat. Ultrasound Obstet Gynecol 1996;7:10-15
  64. 64. 3 D STIC AND INVERSION MODE ANALYSIS
  65. 65. Can a fetus have a heart attack ?
  66. 66. DECOMPENSATION
  67. 67. 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
  68. 68. 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
  69. 69. Redistribution During Fetal Hypoxemia
  70. 70. UMBILICAL ARTERY-High resistance AEDFREDF-PRETERMINAL EVENT
  71. 71. 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 .
  72. 72. FETAL AORTA  AEDF-Per. Vasoconst.- redistribution to MCA.  Acidemia.  Necrotising enterocolitis
  73. 73. CARDIAC FAILURE -VENOUS BLOOD FLOW  Retrograde flow in IVC , DV with atrial contraction  UV pulsations
  74. 74. 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
  75. 75. stage I an abnormal umbilical artery or middle cerebral artery pulsatility index;
  76. 76. stage IIan abnormal MCA PSV,absent/reversed diastolic velocityin the UA,UV pulsation and an abnormal DV PI(an absent DV A wave is consideredpart of thisstage)
  77. 77. 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.
  78. 78. Each stage divided in A & B A is AMNIOTIC FLUID INDEX <5 B is AMNIOTIC FLUID INDEX OF >5
  79. 79.  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.
  80. 80. 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.
  81. 81. Assessment of IUGR Fetus Biometry Fetal assessment for malformation AF Fetal Activity (Biophysical Profile) Color Doppler
  82. 82. IUGR Fetal surveillance Fetal heart rate monitoring Biophysical profile NST CST VAST Fetal blood sampling Color Doppler Study
  83. 83. 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
  84. 84. 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
  85. 85. How to Judge Degree of Hypoxia? Fetal arterial doppler Cut off Line
  86. 86. Fetal arterial circulation Fetal Arterial Circulation – Cut Off Line Redistribution of Blood & brain Sparing EffectCompensatory RedistributionMore flow of oxygenated blood Less flow of oxygenated bloodBrain KidneysMyocardium GITFetal adrenal Limbs, LungsMCA – Nadir reached 2 weeks before fetal jeopardy
  87. 87. Pulsatile Umbilical vein Flow
  88. 88. MCA flowPI More than 1.45 before term Fall down to 1 If less than 1 peak of redistribution
  89. 89. How to Judge degree of Acidemia? Fetal Venous doppler
  90. 90. 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
  91. 91. RA RV HV DV RA RV HV DVGrowth Retardation
  92. 92. Umbilical Veinstudy of 37 fetuses ~~ absent end-diastolic frequenciesin the umbilical arteryNeonatal 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
  93. 93. 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.
  94. 94. Markers For Fetal illness AFI Chronic Marker NST FT Acute Markers FM FBM
  95. 95. 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
  96. 96. Oligohydramnios IndicatesAbnormal BPP independent of other variables because of a risk of cord complications and fetal death.
  97. 97. 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.
  98. 98. 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
  99. 99. Hypoxia & MarkersUmb. pH at which abnormal Test7.20 Abnormal NST<7.20 FBM7.10 - 7.20 Movements< 7.10 ToneThis should be kept in mind for interpretation of Hypoxia andacidosis
  100. 100. Time to deliverFactors 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
  101. 101. Time to deliverWhen 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
  102. 102. 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
  103. 103. Low-RiskSuggestions 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
  104. 104. THANK YOU
  105. 105. Thanks You for Attention

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