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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
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
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
COLOR DOPPLER
Principles of Color Doppler
Color flow mapping
Power Doppler
THE DOPPLER EFFECT
Principles of Color Doppler
Quantitative analysis
Doppler indices
3D DOPPLER
UTERO-PLACENTAL CIRCULATION
• PLACENTAL
CIRCULATION
– progressive maturation of
the placenta and increase in
the number of tertiary stem
villi.
Sadler TW Lagman’s Medical Embryology 1990
Umbilical
vessels Chorionic
vessels
Chorionic
plate Amnion
Spiral
artery
Placental
septumBasal
plate
Uteroplacental
veins
FETAL CIRCULATION
ARTERIAL
VENOUS
CARDIAC HEMODYNAMICS
CLINICAL APPLICATIONS
• Common applications (FGR)
• Other applications (fetal anemia)
• New applications
• 3D Doppler
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
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
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
A DOPPLER REPORT
A REPORT
FETAL HYPOXIA-ACIDOSIS
AORTIC BODY CHEMORECEPTOR
STIMULATION
REFLEX REDISTRIBUTION OF FETAL
CARDIAC OUTPUT
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
UMBILICAL ARTERY
• Low impedance circulation
• S/D index (A/B index)
• Placental insertion has least impedance
• Intervene for absent or reversed EDF
UMB ART SIGNIFICANCE
60% tertiary villous
artery occlusion
>70% tertiary villous artery
occlusion
Trudinger, Br J Obstet Gynecol, 1985
Abuhamad, COG, 2003
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).
UA DOPPLER – REVERSED
DIASTOLIC FLOW
This is an advanced stage of fetal compromise, associated
with increased perinatal morbidity and mortality.
MCA DOPPLER
• Most accessible cerebral vessel
• Carries 80% of cerebral flow
• Excellent reproducibility
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.
MCA DOPPLER
Normal
Abnormal – fetal hypoxia
Alteredcerebroplacental ratio
VENOUS CIRCULATION
Central:
• ductus venosus, hepatic veins, IVC
– characteristic pulsations
Peripheral:
• portal veins, umbilical vein
– no pulsations
DUCTUS VENOSUS
TURBULENCE (DV)
• 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
VENOUS DOPPLER NORMAL
FETUS
IVC Doppler
DV Doppler
HYPOXIC FETUS
IVC Doppler
DV Doppler
OBSTETRIC ULTRASOUND
PROTOCOLS OVER THE YEARS
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
UTERINE CIRCULATION
• Low impedance circulation in pregnancy
• S/D or RI – standard indices
• Low EDF & notching – abnormal findings
• Associated with elevated MS AFP & hCG
UTERINE ARTERY
• Abnormal waveforms:
– FGR
– Pre-eclampsia
– FHR abnormalities
NORMAL & ABNORMAL WAVEFORM
IN ADVANCED PREG
Diastolic Notch
(irrespective of the RI PI))
FGR
• Challenge:
– Diagnose true IUGR
– Identify markers of morbidity
– Intervene in a timely fashion
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
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
SEQUENTIAL CHANGES IN TESTS OF
FETAL WELL BEING
THE ACTION POINTS..
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
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
Early onset severe
FGR
Mild late onset FGR
In severe maternal
disease,
progression is
unpredictable
Aim of monitoring
TO INTERVENE IN TIME
Monitor growth Biometry
Detect hypoxia Doppler
PreventacidemiaDoppler/BPP/ CTG

Daily fetal movement count
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
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
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
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.
NEW APPLICATIONS
Umbilical artery notching:
• Cord entanglement
• True knot
• Cord stricture
• Velamentous insertion
• Tight nuchal cords
• Abnormal cord coiling
JUM 2002;21:857
PLACENTA - 3D DOPPLER
VASCULARIZATION INDEX (VI)
• VI = measures % of color pixels in ROI that
represent flow
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)
3-D CALCULATIONS
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.
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
STAGE I
• an abnormal umbilical artery or middle cerebral
artery pulsatility
• index;
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)
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.
EACH STAGE DIVIDED IN A & B
• A is AMNIOTIC FLUID INDEX <5
• B is AMNIOTIC FLUID INDEX OF >5
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
• 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.
• 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.
• 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.
• Another advantage is the simplicity of
the system.
• Only 4 fetal vessels and 1 cardiac valve
need
to be investigated with Doppler
ultrasonography.
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
• 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
• 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.
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
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
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
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
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.
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
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)
When to deliver?
<28wks
Difficult decision
Counseling
Challenge to the neonatologist
When to deliver?
>34weeks
Low threshold for delivery
Abnormal doppler
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
When to deliver?
28-32weeks
Absent or reversal of EDV in venousdoppler(DV)
Abnormal Biophysical profile
Spontaneous decelerations
When to deliver?
<28weeks
Difficult decision
Parents to be extensively counseled
Challenge for the paediatriciansin terms of
prolonged care
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
BERLIN C0NCENSUS
ROAD TO DEATH
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
Take home message
Majority occur in low risk pregnancies
Prospective screening of all pregnancies may help
in predicting FGR- debatable
Take home message
Commonly due to ischemic placental disease
No therapeutic intervention to reverse the process
Timing of delivery is crucial tooptimiseoutcome
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
Take home message
Deliver at 34wks/ deterioration
Doppler particularly venousdoppleris the
cornerstone of monitoring
Prepare thepaedsand the parents
Intervene before acidosis sets in
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.
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)
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
4 of our latest books released
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Color doppler in FGR making sence of waves

  • 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
  • 5. Principles of Color Doppler Color flow mapping Power 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
  • 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
  • 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.
  • 29. VENOUS CIRCULATION Central: • ductus venosus, hepatic veins, IVC – characteristic pulsations Peripheral: • portal veins, umbilical vein – no pulsations
  • 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
  • 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
  • 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)
  • 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)
  • 78.
  • 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
  • 86.
  • 87.
  • 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
  • 98.