hypertension in pregnancy

1. ULTRASONOGRAFIA DOPPLER INULTRASONOGRAFIA DOPPLER IN
HIPERTENSIUNEAARTERIALAHIPERTENSIUNEAARTERIALA
INDUSA SAU ASOCIATA SARCINIIINDUSA SAU ASOCIATA SARCINII
Alexandru AndritoiuAlexandru Andritoiu
Sp. Militar de UrgentaSp. Militar de Urgenta
CraiovaCraiova

2. US in sarcinaUS in sarcina
 2D-RT2D-RT
 3D3D
 4D4D
 Doppler spectralDoppler spectral
(PWD,CWD)(PWD,CWD)
 Doppler colorDoppler color
 Power-angioPower-angio
 Biometria fetalaBiometria fetala
 Virsta sarciniiVirsta sarcinii
 Index amnioticIndex amniotic
 Sarcina gemelaraSarcina gemelara
 Malformatii fetaleMalformatii fetale
 HemodinamicaHemodinamica
utero-placentarautero-placentara
cerebralacerebrala
- fetala- fetala
- materna- materna

3. US Doppler obstetricalaUS Doppler obstetricala
 PreeclampsiePreeclampsie
 RCIURCIU
 Deces perinatalDeces perinatal
 Nasterea prematuraNasterea prematura
 Suferinta fetalaSuferinta fetala
 Interventia cezarianaInterventia cezariana

4. Parametrii DopplerParametrii Doppler
 S (cm/s)S (cm/s)
 D (cm/s)D (cm/s)
 Index Stuart S/DIndex Stuart S/D
 Index diastolic D/SIndex diastolic D/S
 Index placentar S-D/SIndex placentar S-D/S
 IP Goslin (S-D)/mIP Goslin (S-D)/m
 IR Pourcelot (S-D)/DIR Pourcelot (S-D)/D
 Index Cerebro-Placentar Ro/RcIndex Cerebro-Placentar Ro/Rc

5. Zone de interesZone de interes
 AA ombilicaleAA ombilicale
Rezistenta placentara – cresterea fetalaRezistenta placentara – cresterea fetala
 Aa uterine (aa arcuate)Aa uterine (aa arcuate)
Versantul matern al circulatiei utero-Versantul matern al circulatiei utero-
placentareplacentare
 Aa cerebrale fetaleAa cerebrale fetale
Suferinta fetala (hipoxia cerebrala)Suferinta fetala (hipoxia cerebrala)
 Vena ombilicalaVena ombilicala
 Canal venos ArantiusCanal venos Arantius
 Aa cerebrale materneAa cerebrale materne
a) abord US transabdominal
b) abord US transvaginal

6. Velocimetria ombilicalaVelocimetria ombilicala
 EvolutivaEvolutiva
 Creste indexul diastolicCreste indexul diastolic
 Scade raportul S/DScade raportul S/D
 Scade IRScade IR
 Determinarea sa importanta dupa al II-lea trim.Determinarea sa importanta dupa al II-lea trim.

7. Evolutia indexului placentarEvolutia indexului placentar
(dupa Uzan M 1991)

8. Profilul patologic al AOProfilul patologic al AO
 Diminuarea DDiminuarea D
 Diastola nulaDiastola nula
 Revers –flowRevers –flow
 Impedanta crescutaImpedanta crescuta
 RCIU
 HIS
 PE severa
NB. Semnificatia patologica a traseului Doppler ombilical – dupa 22 spt de amenoree

9. Valoarea prognostica a velocimetrieiValoarea prognostica a velocimetriei
ombilicale in HISombilicale in HIS
 Riscul fetal-proportional cuRiscul fetal-proportional cu
severitatea modificarilorseveritatea modificarilor
DopplerDoppler
 Absenta fluxului D –VPPAbsenta fluxului D –VPP
92% asfixia prenatala92% asfixia prenatala
 Corelabila cu aparitia RCIUCorelabila cu aparitia RCIU
in HISin HIS
 Utila in ajustarea schemelorUtila in ajustarea schemelor
terapeutice antihipertensiveterapeutice antihipertensive

10. Velocimetria ombilicala – test de screening ?Velocimetria ombilicala – test de screening ?
A) Populatia neselectionataA) Populatia neselectionata
Brown MA et al. 1990Brown MA et al. 1990
 272 gravide (>26. spt)272 gravide (>26. spt)
167 sarcina normala167 sarcina normala
61 HIS61 HIS
44 DZ44 DZ
Anom. Doppler AU – la 7% !Anom. Doppler AU – la 7% !
Sp 95-97%Sp 95-97%
Sb 16-17%Sb 16-17%
B) Gravida cu risc crescutB) Gravida cu risc crescut
Neilson JP et al. 2002Neilson JP et al. 2002
 Meta-analiza (10 studii)Meta-analiza (10 studii)
 700 gravide cu risc crescut700 gravide cu risc crescut
 Anom. Doppler AO asociat:Anom. Doppler AO asociat:
Reducerea deceselor perinataleReducerea deceselor perinatale
(odds ratio 0.71)(odds ratio 0.71)
Mai putine indicatii de declansare aMai putine indicatii de declansare a
nasteriinasterii
(odds ratio 0.56)(odds ratio 0.56)
Nu diferera rata suferintei perinataleNu diferera rata suferintei perinatale
(odds ratio 0.81)(odds ratio 0.81)
Nu difera rata interventiei cezarieneNu difera rata interventiei cezariene
(odds ratio 0.94)(odds ratio 0.94)

11. Velocimetria uterinaVelocimetria uterina

12. Profilul spectral normalProfilul spectral normal
 Flux cu rezistenta scazutaFlux cu rezistenta scazuta
 Index uterin normal:Index uterin normal:
 D/S >0.4D/S >0.4
 IR >0.6IR >0.6
 S/D >2.6S/D >2.6
 no notch >26-28 spt.no notch >26-28 spt.

13. Parametrii Doppler normali ai AUParametrii Doppler normali ai AU
(rezultate obtinute la un lot de 45 gravide cu sarcina normala)(rezultate obtinute la un lot de 45 gravide cu sarcina normala)
IPIP 0.660.66
IRIR 0.550.55
S (m/s)S (m/s) 0.400.40
D (m/s)D (m/s) 0.200.20
S/DS/D 2.202.20
D/SD/S 0.500.50
Dinamica indexului de rezistenta IR
(Pourcelot) al AU
0
0.5
1
durata amenoree 20- 40 spt. IR
Dinamica velocitatilor maxime S si D in
AU
0
20
40
60
durata amenoree 20-40 spt.
cm/s
S
D
Andritoiu A, Raca N 2003

14. Profil uterin anormalProfil uterin anormal
 RCIURCIU
 HTA cronicaHTA cronica
 PEPE
 DZDZ
 Hematom retroplacentarHematom retroplacentar
 Malformatii fetaleMalformatii fetale

15. Criterii obiectiveCriterii obiective
 Grade notch (1-3)Grade notch (1-3)
 A/CA/C
 D-C/BD-C/B
 Notch index C-D/CNotch index C-D/C
 IP(IR)IP(IR)
Bromley B 1994, North RA 1994, Moutquin JM 1996, Uzan M 1996,
Bower S 1998, Becker R 2002, Godmundsson S 2002
C
A
B
D

16. Valoarea predictiva in PEValoarea predictiva in PE
AutorAutor Preval. PEPreval. PE SbSb
(%)(%)
SpSp
(%)(%)
VPPVPP
(%)(%)
VPNVPN
(%)(%)
Campbell 1986Campbell 1986 11.911.9 6767 6464 2020 8383
Hanretty 1989Hanretty 1989 24.124.1 77 9494 2626 7676
Steel 1990Steel 1990 1.91.9 6363 8989 1010 9999
Valensise 1993Valensise 1993 3.33.3 8989 9393 3131 9999
Bower 1993Bower 1993 1.81.8 7878 9595 2222 9999
North 1994North 1994 3.33.3 2727 9090 88 9797
Frusca 1997Frusca 1997 1.91.9 5050 9292 1111 9999
Kurdi 1998Kurdi 1998 2.22.2 6262 8989 1111 9999

17. Velocimetria cerebralaVelocimetria cerebrala
fetalafetala

18. ACM fetala - profil spectral fiziologicACM fetala - profil spectral fiziologic
 S ampluS amplu
 D crestere cu virsta sarciniiD crestere cu virsta sarcinii
 IR scade la termenIR scade la termen
 Index cerebro-placentarIndex cerebro-placentar
(Arbeille PH)(Arbeille PH)
ICP = IR cer / IR omb > 1ICP = IR cer / IR omb > 1
Dinamica ID (D/S) al ACM fetale
16
18
20
22
durata amenoree 20-40 spt.
D/S
ID
Dinamica indexului de rezistenta (Pourcelot) al
ACM fetale
Rc = S-D / S
0.74
0.76
0.78
0.8
0.82
0.84
durata amenoree 20-40 spt.
IR
IR

19. Dinamica indexului cerebro-placentarDinamica indexului cerebro-placentar
Dinamica indexului cerebro-placentar
1.1
1.15
1.2
1.25
1.3
1.35
ICP = Rc / Rp ICP
Andritoiu Al, Raca N 2003

20. Velocimetria cerebrala maternaVelocimetria cerebrala materna
 Studiul hemodinamicii cerebrale materneStudiul hemodinamicii cerebrale materne
 In PE / EIn PE / E
 Scade impendanta aa cerebrale materneScade impendanta aa cerebrale materne

21. Parametrii spectrali ACMm in sarcinaParametrii spectrali ACMm in sarcina
20-24 spt20-24 spt 25-28 spt25-28 spt 29-32 spt29-32 spt 33-36 spt33-36 spt 37-40 spt37-40 spt
IPIP 0.940.94 1.021.02 0.850.85 0.940.94 0.870.87
IRIR 0.640.64 0.620.62 0.580.58 0.590.59 0.570.57
S (m/s)S (m/s) 1.031.03 1.211.21 0.940.94 1.171.17 0.880.88
D (m/s)D (m/s) 0.370.37 0.460.46 0.390.39 0.450.45 0.400.40
S/DS/D 2.72.7 2.62.6 2.52.5 2.52.5 2.32.3
TM(m/s)TM(m/s) 0.650.65 0.690.69 0.680.68 0.760.76 0.570.57
Andritoiu Al, Raca N 2003

22. CONCLUZIICONCLUZII
 Velocimetria DopplerVelocimetria Doppler
utero-placentara –utero-placentara –
predictiva in aparitiapredictiva in aparitia
complicatiilor vascularecomplicatiilor vasculare
maternematerne
 Velocimetria cerebralaVelocimetria cerebrala
fetala – utila in suferintafetala – utila in suferinta
fetala inaintea aparitieifetala inaintea aparitiei
tb de ritm cardiactb de ritm cardiac