lecture delivering todaqy at WCPM ian donald workshop on USG at BELGRADE sava centre

1. PROF.NARENDRA MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.M.A.S.,F.I.A.P.
• Prof. Dubrovnick International University
• V.P. WAPM(world association of prenatal medicinne)
• President ISAR
• Presiddent Elect ISPAT
• Sec Gen SAFOG
• Member FIGO guidelines committee
• President FOGSI (2008-2009)
• Dean I.C.M.U. (2008)
• Director Ian Donald School of Ultrasound
• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course
• Managing Director GLOBAL RAINBOW HEALTH CARE
• Director ART-RAINBOW –IVF
• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy
and Infertility, ART & Genetics
• Member and Fellow of many Indian and international organisations
• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,
Corion award, Man of the year award, Best Citizens of India award
• Over 50 published and 200 presented papers
• Over 100 guest lectures given in India & Abroad and 24 ORATIONS
• Organised many workshops, training programmes, travel seminars and conferences
• Editor 18 books, many chapters, on editorial board of many journals
• Editor of series of STEP by STEP books
• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)
• Very active Sports man, Rotarian and Social worker
MALHOTRA NURSING & MATERNITY HOME PVT. LTD.
GLOBAL RAINBOW HEALTH CARE,AGRA
84, M.G. Road, Agra-282 010
Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194

2. Color doppler in FGR making
sense of the waves
Narendra Malhotra
Jaideep Malhotra
Neharika Malhotra Bora
Rishabh Bora
Ashok Khurana,S Suresh,Kuldeep Singh
www.rainbowhospitals.org
mnmhagra3@gmail.com

3. OBJECTIVES OF THIS TALK
• Describe Doppler technique in different blood vessels
• Discuss Doppler role in FGR fetuses
• Understand the value of Doppler in fetal anemia
• Present Doppler frontiers

4. COLOR DOPPLER

5. Principles of Color Doppler
Color flow mapping
Power Doppler

6. THE DOPPLER EFFECT

7. Principles of Color Doppler

8. Quantitative analysis
Doppler indices

9. 3D DOPPLER

10. UTERO-PLACENTAL CIRCULATION
• PLACENTAL
CIRCULATION
– progressive maturation of
the placenta and increase in
the number of tertiary stem
villi.

11. Sadler TW Lagman’s Medical Embryology 1990
Umbilical
vessels Chorionic
vessels
Chorionic
plate Amnion
Spiral
artery
Placental
septumBasal
plate
Uteroplacental
veins

12. FETAL CIRCULATION
ARTERIAL
VENOUS
CARDIAC HEMODYNAMICS

13. CLINICAL APPLICATIONS
• Common applications (FGR)
• Other applications (fetal anemia)
• New applications
• 3D Doppler

14. DOPPLER IN IUGR
• To identify etiology of FGR
– Placental / non placental
• To identify hypoxia & fetal adaptation
• To plan timing of delivery?
• To identify fetuses at risk of perinatal complications

15. DOPPLER IN FGR
• To identify vascular bed resistance
– Uterine artery
– Umbilical artery
• To identify fetal adaptation
– MCA
• To identify cardiac decompensation
– Ductus venosus
– Umbilical vein

16. DOPPLER IN FGR
Doppler meta analysis has shown that the use of the UA
Doppler reduces the number of:
• antenatal admissions: 44%
• inductions of labor: 29%
• C/S for NRFS: 52%
• perinatal mortality: 38%
Alfirevic Z, Neilson JP
ACOG 1995;172;1379-87

17. A DOPPLER REPORT

18. A REPORT

19. FETAL HYPOXIA-ACIDOSIS
AORTIC BODY CHEMORECEPTOR
STIMULATION
REFLEX REDISTRIBUTION OF FETAL
CARDIAC OUTPUT

20. REFLEX REDISTRIBUTION OF FETAL
CARDIAC OUTPUT
INCREASED FLOWDECREASED FLOW
 KIDNEYS (OLIGURIA)
(OLIGOAMNIOS)
 LUNGS (RDS)
 GUT (NEC)
 LIVER/MUSCLE (IUGR)
BODY FAT/
GLYCOGEN STORES
 BRAIN
 ADRENALS
 HEART

21. UMBILICAL ARTERY
• Low impedance circulation
• S/D index (A/B index)
• Placental insertion has least impedance
• Intervene for absent or reversed EDF

22. UMB ART SIGNIFICANCE
60% tertiary villous
artery occlusion
>70% tertiary villous artery
occlusion
Trudinger, Br J Obstet Gynecol, 1985
Abuhamad, COG, 2003

23. ABNORMAL UMB A
WAVEFORMS
DECREASED EDF ABSENT EDF REVERSED EDF
Nicolaides, Placental and Fetal Doppler
Diploma in Fetal Medicine Series, 2000
Absent / Reversed End Diastolic flow
is associated with severe IUGR, oligohydramnios,
increased risk of neonatal mortality and morbidity
(cerebral hemorrhage, anemia and hypoglycemia).

24. UA DOPPLER – REVERSED
DIASTOLIC FLOW
This is an advanced stage of fetal compromise, associated
with increased perinatal morbidity and mortality.

25. MCA DOPPLER
• Most accessible cerebral vessel
• Carries 80% of cerebral flow
• Excellent reproducibility

26. MIDDLE CEREBRAL ARTERY
“FETAL ADAPTATION”
31 weeks, IUGR, PI=1.22 33 weeks, IUGR, PI=1.11
Decreasing trend in MCA PI suggests further
blood flow redistribution to the brain.

27. MCA DOPPLER
Normal
Abnormal – fetal hypoxia

28. Alteredcerebroplacental ratio

29. VENOUS CIRCULATION
Central:
• ductus venosus, hepatic veins, IVC
– characteristic pulsations
Peripheral:
• portal veins, umbilical vein
– no pulsations

30. DUCTUS VENOSUS
TURBULENCE (DV)

31. • Reversal of A- wave flow in the DV - sensitivity of 53% for
perinatal mortality.
• A-velocity below the 5th percentile in DV - 79%
sensitivity for fetal demise.
A cut-off value for DV PIV of 2–3 SD seems to be most
appropriate for delivery. (C. M. BILARDO et al, UOG, 2004)
1st tri 2nd Tri 3rd tri
Normal DV wave forms

32. VENOUS DOPPLER NORMAL
FETUS
IVC Doppler
DV Doppler

33. HYPOXIC FETUS
IVC Doppler
DV Doppler

34. OBSTETRIC ULTRASOUND
PROTOCOLS OVER THE YEARS

35. UTERINE ARTERY DOPPLER FOR
PREDICTON OF IUGR
LR ut art dop IUGR
LR
Pre-eclampsia
LR
Perinatal death
LR
ABN 3.7 5 2.4
N 0.7 0.5 0.8

36. UTERINE CIRCULATION
• Low impedance circulation in pregnancy
• S/D or RI – standard indices
• Low EDF & notching – abnormal findings
• Associated with elevated MS AFP & hCG

37. UTERINE ARTERY
• Abnormal waveforms:
– FGR
– Pre-eclampsia
– FHR abnormalities

38. NORMAL & ABNORMAL WAVEFORM
IN ADVANCED PREG
Diastolic Notch
(irrespective of the RI PI))

39. FGR
• Challenge:
– Diagnose true IUGR
– Identify markers of morbidity
– Intervene in a timely fashion

40. Evaluation of FGR
PIH/ HT/ DM/
Renal disease
Previous FGR /
Still birth
APA
Maternal
Fetal
USGto R/O
structural
abnormalities
Fetal echo
Invasive fetal testing
Karyotyping
Fetal infections

41. TIMELINE FOR FETAL HYPOXIA
DOPPLER SUMMARY
• Abnormal fetal growth
• Abnormal arterial Doppler (UA, MCA)
~ 2 weeks
• Abnormal venous Doppler (IVC & ductus venosus)
~ 1-2 days??
• Abnormal NST / BPP score

42. SEQUENTIAL CHANGES IN TESTS OF
FETAL WELL BEING

43. THE ACTION POINTS..

44. Doppler
Incflow FetalMCA
PI< 5th
Umbilical artery HRF PI> 95th
placental
resistance
increasing
hypoxia
acidosis Venoussystem-
Ductusvenosus/umbveinearly/ late
Cerebroplacen
talratio
MCA PI/ UA PI <1 or < 5thcentile

45. Early vs Late onset FGR
Both have poorlongtermneurodevelopmental,
cardiovascular, and metabolicparametres
Both are associated with placental disease but
may be different types of disease
GAcutoffis arbitrary and could be 32 weeks

46. Early onset severe
FGR
Mild late onset FGR
In severe maternal
disease,
progression is
unpredictable

47. Aim of monitoring
TO INTERVENE IN TIME
Monitor growth Biometry
Detect hypoxia Doppler
PreventacidemiaDoppler/BPP/ CTG

Daily fetal movement count

48. MONITORING – HOW OFTEN?
 Frequency dictated by
 Severity of growth restriction
 Gestational age of the fetus
 Biometry
 2 – 3 weeks
 No value for biometry if interval is less than 2 weeks
 Doppler
 2 – 3 weeks if mild
 weekly / biweekly if severe dysfunction
 AFI – weekly / bi weekly

49. DOPPLER & FETAL ANEMIA
• Anemia:
– Increased cardiac output
– Decreased blood viscosity
– Increased blood velocity
• Peak systolic velocity of MCA
• Why MCA?
– Increased blood flow to brain in anemic fetus
– MCA lends itself to insonation angle close to zero
– Low inter- and intra-observer variability

50. DOPPLER & FETAL ANEMIA
MCA PSV:
• Moderate to severe anemia:
– Sensitivity 100%
– FPR 12%
Mari C et al. NEJM 2000;342:9
• Parvo virus
– Sensitivity 94.1%
– Specificity 93.3%
ACOG 2002

51. Aghajanian P et al. Fetal middle cerebral artery Doppler
fluctuations after laser surgery for twin-twin transfusion syndrome.
J Perinatol. 2011 May;31(5):368-72. Epub 2010 Dec 9.
• The objective to compare alterations in the MCA PI and
mean velocity (V mean) after laser surgery for twin-twin
transfusion syndrome (TTTS).
• Despite the changes in the MCA PI after laser for TTTS, the
MCA V (mean) remained constant.
• These findings may suggest some autoregulatory capacity
in the cerebral vessels of the mid-trimester fetus.

52. NEW APPLICATIONS
Umbilical artery notching:
• Cord entanglement
• True knot
• Cord stricture
• Velamentous insertion
• Tight nuchal cords
• Abnormal cord coiling
JUM 2002;21:857

53. PLACENTA - 3D DOPPLER

54. VASCULARIZATION INDEX (VI)
• VI = measures % of color pixels in ROI that
represent flow

55. FLOW INDEX (FI) & VASCULARIZATION
FLOW INDEX (VFI)
• FI = measures intensity of color pixels in ROI
• VFI = combines % of color pixels and intensity in ROI
(0-100 normalized)

56. 3-D CALCULATIONS

57. J Ultrasound Med 26:1469-1477 • 0278-4297
Staging of Intrauterine Growth-Restricted Fetuses
Giancarlo Mari, MD, Farhan Hanif, MD, Kathrin Drennan, MD and Michael Kruger, MA
• The staging system proposed here
may allow comparison of outcome
data for IUGR fetuses and may be
valuable in determining more
timely delivery for these high-risk
fetuses.

58. 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

59. STAGE I
• an abnormal umbilical artery or middle cerebral
artery pulsatility
• index;

60. 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)

61. 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.

62. EACH STAGE DIVIDED IN A & B
• A is AMNIOTIC FLUID INDEX <5
• B is AMNIOTIC FLUID INDEX OF >5

63. Staging of Intrauterine
Growth-Restricted Fetuses
Giancarlo Mari, MD, Farha n Hanif, MD,
Kathrin Drennan, MD, Michael Kruger, MA
• The purpose of this study was 2-fold: (1) to
assess the clinical relevance of a staging
system for IUGR fetuses that would include
ultrasonographic, Doppler, and clinical data;
and (2) to
propose a classification that can be used for
all types of IUGR fetuses

64. • 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.

65. • Stage I fetuses have mild IUGR, and we
can treat these patients as outpatients
• stage II and III patients need to be
admitted to
the hospital.
• Stage II patients are admitted for
observation,
• stage III patients are at
• high risk for fetal death.

66. • The major advantage of selecting the
parameters included in this staging
system is the ability to clearly track the
progression of abnormal parameters
that start at the UA and MCA and later
to progressively extend the evaluation
to the other parameters up to the time
of fetal death if the fetus remain
undelivered.

67. • Another advantage is the simplicity of
the system.
• Only 4 fetal vessels and 1 cardiac valve
need
to be investigated with Doppler
ultrasonography.

68. Furthermore, it is not necessary to determine the
parameters reported for a certain stage if the
parameters of the previous stage are normal. For
example, if the UA and MCA PI values are normal,
it is not necessary to determine the parameters
of the next stage
This makes the staging
system easily applicable

69. • Our data indicate that the staging system proposed
• here is applicable in pregnancies at gestational
• ages of both less than and greater than 30
• weeks, which makes the staging system reliable
• with regard to different gestational ages

70. • If a fetus has an estimated fetal
• weight below the 10th percentile and both the
• UA PI and the MCA PI are normal, we classify it
• as stage 0.

71. 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

72. Timing of delivery- TRUFFLE
The objective ofthis studywas to describeperinatal
morbidity andmortalityfollowingearly-
onsetfetalgrowth restriction basedontimeof
antenatal diagnosis anddelivery
Outcomes
perinatal death
severe perinatal morbidity
Trial of randomised umbilical andfetalflow in Europe
Lees et al, UltrasoundObstetGynecol2013

73. TRUFFLE
Recruitment of very early FGRs26-32 weeks with
EFW < 10thcentile and UA PI > 95thcentile
Delivery based on
ARM1 abnormal CTG/ reduced STV
ARM2 early DVchanges-PI>95thcentile
ARM3late DV changes absent orreverseda wave

74. TRUFFLE-Implications for
management
< 30 weeks
Management based on
DV
Neuro outcome better if
delivery is based on
absent or reversed ‘a’
wave
Or
If CTG STV is abnormal
After 30 weeks, deliver
if:
30-32wks-reversed
EDF
32-34wks- absent EDF
34-36wks- increased PI

75. PREGNANCY MANAGEMENT
• Abnormal UA Doppler
– Decreased diastolic flow
• Increase frequency of testing; consider deliver
>37 weeks
– Absent end diastolic flow
• Steroids; consider delivery at 34 weeks
– Reversed end diastolic flow
• Steroids: consider delivery at 32 weeks
Am J Obstet Gynecol. 2012 Apr;206(4):300-8.

76. PREGNANCY MANAGEMENT
• 37 or more: delivery if NRFS; elective
delivery after 38-39 weeks
• <34 weeks:
– Expectant management if reassuring fetal
status – Rx corticosteroids for fetal benefits
– Modified bed rest, smoking cessation, Rx
hypertension
– Antepartum testing: NST/AFI & BPP twice
weekly, daily kick counts, UA Doppler
– Abnormal UA Doppler: daily NST and at least
twice weekly BPP for up to 2 weeks
– Non-reassuring status: evaluate for delivery

77. PREGNANCY MANAGEMENT
• 34-37 weeks
– Management individualized
– Antepartum testing: NST/AFI twice weekly, UA
Doppler
– Non-reassuring status: evaluate for delivery
– Oligohydramnios and abnormal UA Doppler: more
frequent antepartum testing but not delivery
(unless non-reassuring status)

79. When to deliver?
<28wks
Difficult decision
Counseling
Challenge to the neonatologist

80. When to deliver?
>34weeks
Low threshold for delivery
Abnormal doppler

81. When to deliver?
32-34weeks
Continue to monitor when high resistance in UA
and cerebral redistribution
Absent or reversed EDV is an indication for
immediate delivey

82. When to deliver?
28-32weeks
Absent or reversal of EDV in venousdoppler(DV)
Abnormal Biophysical profile
Spontaneous decelerations

83. When to deliver?
<28weeks
Difficult decision
Parents to be extensively counseled
Challenge for the paediatriciansin terms of
prolonged care

84. Planning mode of delivery
SGA
umbilical artery AREDV
Cesareansection
SGA
normal umbilical artery Doppler or
with abnormal umbilicalarteryPI but
end–diastolic velocitiespresent
Induction can be offered
continuousmonitoring
SGA with normaldoppler
Senior input about time
/ mode
Continuous CTG

85. BERLIN C0NCENSUS

88. ROAD TO DEATH

89. Take home message
SGA is a complex diagnostic exercise and FGR is
a significant perinatal problem
Distinction between growth restricted baby and a
low growth potential baby is a critical issue

90. Take home message
Majority occur in low risk pregnancies
Prospective screening of all pregnancies may help
in predicting FGR- debatable

91. Take home message
Commonly due to ischemic placental disease
No therapeutic intervention to reverse the process
Timing of delivery is crucial tooptimiseoutcome

92. Take home message
Dating of pregnancy is vital
Serial scans may be required
Growth charts
Rule out underlying cause- aneuploidy and
infections in early onset FGR whendopplersare
normal

93. Take home message
Deliver at 34wks/ deterioration
Doppler particularly venousdoppleris the
cornerstone of monitoring
Prepare thepaedsand the parents
Intervene before acidosis sets in

94. CONCLUSIONS
• Doppler ultrasound is integral part in management of
IUGR, fetal anemia, placental abnormalities, twins
• 3D Doppler is a unique technique that enables
assessment of vascular signals within the whole
investigated area.
• Homodynamic changes included in the process of
placentation are one of the most exciting topics in the
investigation of human development.

95. WHEN DOPPLER STUDY IS
NORMAL
The diagnosis of IUGR is doubtful
(Brodoszki, et al., 2002)
It may be a constitutionally small normal
fetus (Burket et al, 1990, Pattnson, et al
1994)
Small fetus with normal Doppler left
unmonitored (Baschat and Weiner,
2000)
Expectant management on continued
surveillance (Harman and Baschat, 2003)

96. If Doppler is
available
It may identify a fetus with IUGR
who registers later and you are
uncertain of the gestational age
Low-Risk
Suggestions
Doppler French Study Group
Br J Obstet Gynecol 1997, 104:419

97. 4 of our latest books released

99. Thank You