department of radio-diagnosis j.j.m.medical college

ROLE OF DOPPLER ULTRASONOGRAPHY IN

PREDICTION OF ADVERSE PERINATAL OUTCOME IN INTRAUTERINE GROWTH

RETARDATION

by

Dr. SHYLAJA.N. M.B.B.S.,

Dissertation submitted to the Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

in partial fulfillment

of the requirements for the degree of

DOCTOR OF MEDICINE IN

RADIO-DIAGNOSIS

Under the guidance of Dr. KIRAN KUMAR HEGDE.S.

Associate Professor

DEPARTMENT OF RADIO-DIAGNOSIS J.J.M.MEDICAL COLLEGE.

DAVANGERE 2006-2009

I

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka

DDEECCLLAARRAATTIIOONN BBYY TTHHEE CCAANNDDIIDDAATTEE

I here by declare that this dissertation titled “ROLE OF DOPPLER

ULTRASONOGRAPHY IN PREDICTION OF ADVERSE PERINATAL

OUTCOME IN INTRAUTERINE GROWTH RETARDATION”

is a bonafide and genuine research work carried out by me under the

guidance of Dr. KIRAN KUMAR HEGDE .S., Associate Professor,

Department of Radio-Diagnosis, J.J.M. Medical College. Davangere.

Dr. SHYLAJA. N. Post Graduate in Radio-Diagnosis

Place: Davangere J.J.M.MEDICAL COLLEGE Date: Davangere.

CCEERRTTIIFFIICCAATTEE BBYY TTHHEE GGUUIIDDEE

This is to certify that this dissertation titled “ROLE OF DOPPLER


OUTCOME IN INTRAUTERINE GROWTH RETARDATION” is a

bonafide work done by Dr. SHYLAJA.N., in partial fulfillment of the

requirement for the award of M.D. Degree in Radio-Diagnosis.

Date: Place: Davangere Dr. KIRAN KUMAR HEGDE . S. Associate Professor

Department of Radio-Diagnosis JJM Medical College, Davangere – 577 004

ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF

THE INSTITUTIONTHE INSTITUTION

This is to certify that the dissertation entitled “ROLE OF DOPPLER


OUTCOME IN INTRAUTERINE GROWTH RETARDATION” is a

bonafide research work done by Dr. SHYLAJA .N, under the guidance of

Dr. KIRAN KUMAR HEGDE. S., Associate Professor, Department of

Radio-Diagnosis, J.J.M.Medical College, Davangere.

Date: / / 2008 Date: / / 2008

Place: Davangere Place: Davangere

Dr. RAMESH S. DESAI M.D., D.M.R.D., Professor and Head, Department of Radio-Diagnosis, J.J.M. Medical College, Davangere – 577 004.

Dr. H.R. CHANDRASEKHAR M.D., Principal, J.J.M. Medical College, Davangere – 577 004.

CCOOPPYYRRIIGGHHTT

DDeeccllaarraattiioonn bbyy tthhee CCaannddiiddaattee

I hereby declare that the Rajiv Gandhi University of Health Sciences,

Karnataka shall have the rights to preserve, use and disseminate this

dissertation/.thesis in print or electronic format for academic / research

purpose.

Date : / / 2008 Dr. SHYLAJA.N. Place: Davangere

© Rajiv Gandhi University of Health Sciences, Karnataka

AACCKKNNOOWWLLEEDDGGEEMMEENNTT

It gives me immense pleasure to express my deep sense of gratitude and

sincere thanks to my beloved teacher and guide Dr. KIRAN KUMAR

HEGDE S. M.D., Associate professor, Department of Radio Diagnosis, J.J. M. Medical

College, Davangere, who with his knowledge and professional expertise has provided

able guidance and constant encouragement throughout the course of study and in the

preparation of this dissertation.

I am extremely grateful and highly indebted to Dr. RAMESH S. DESAI M.D.,

D.M.R.D., Professor and Head, Department of Radio Diagnosis, J.J.M. Medical College,

Davangere, for his selfless devotion to his students, guidance, support and constant

encouragement during the period of my study.

I also express my sincere gratitude to Dr. V.N.NARVEKAR M.D, Former

Professor for inspiring me to take up this study and for his expert guidance, advice

and encouragement.

My sincere thanks to my Professors, Dr. J.PRAMOD SETTY M.D, Professor,

Dr. K.N.SHIVAMURTHY M.D, Professor, DR.R.SRINIVAS, M.D Professor, and

Dr. M. B. SIDDESH M.D. Assistant Professor, for their encouragement.

I express my sincere gratitude to DR. BHAGYAVATHI M, M.D, D.M.R.D.,

Associate Professor and Dr. JEEVIKAM.U.M.D, Reader, for their constatnt support

and encouraging words which has helped me to sail through hardships of life.

I am extremely thankful to Dr. H.R.CHANDRASEKHAR, M.D, Principal,

J.J.M. Medical College, Davangere, Dr. H.GURUPADAPPA, M.D , Director for

Postgraduate Students and Research, J.J.M. Medical College, Davangere, for their

valuable help and co-operation during this study.

VI

I also express my sincere thanks to the superintendents and technicians of

Chigateri General Hospital and Bapuji Hospital, Davangere, for allowing me to study

the patients of their hospital.

I wish to thank my parents Smt. NAGARATHNA. R. and

Sri, NAGARAJU .N for their unconditional support and blessings, they are a

constant guiding force in my life for which I will always feel blessed.

My heart felt thanks to my dear loving Husband Mr. PRASHANTH .G. for

his constant support and love which helps me to conquer any battle of life.

My heartful thanks to my inlaws Smt. ANASUYA and Sri. GOVINDRAJU

for their moral support and blessings throughout my study.

My special thanks to my friends Dr. RAVISHANKAR,

Dr. SUMATHI.M.E., Dr. MANJUNATH.B, Dr. RAMKUMAR, Dr. BHASKAR,

and Dr. RAJSHEKHAR for their moral support and help in preparation of this

dissertation.

I thank Mr. P.S. MAHESH , Chief Librarian and other staff of the Central

Library for their help during my research and cross reference work.

I would also like to thank all the staff members of THOMAS COMPUTERS

and BENAKA PRINTERS for their efficient work of this dissertation.

Lastly I thank everyone concerned, including the patients for their

cooperation, without whom this dissertation would have ever materialized.

I am ever greatful to the ALMIGHTY for his blessings on me.

PLACE: Davangere

DATE: / /2008 [Dr. SHYLAJA.N.]

Dedicated To My

Beloved Parents & Lord Almighty

LIST OF ABBREVIATIONS USED

AEDF - Absent End Diastolic Flow

AUAPI - Abnormal Umbilical artery PI

CS - Caesarian Section

EDF - End diastolic Flow

FVW - Flow Velocity wave forms

FN - False negative

FP - False Positive

IUGR - Intra Uterine Growth Retardation / Restriction

IUD - Intra uterine Death

IVH - Intra Ventricular Haemorrhage

LMP - Last Menstrual Period

MCA - Middle Cerebral Artery

MCAPI - Middle Cerebral Artery Pulsatility Index

NEC - Necrotising Enterocolitis

NICU - Neonatal Intensive Care Unit

NPV - Negative Predictive Value

NUAPI - Normal Umbilical Artery PI

PI - Pulsatility Index

PIH - Pregnancy Induced Hypertension

PO2 - Partial Pressure of Oxygen

PPV - Positive Predictive Value

RDS - Respiratory Distress Syndrome

RI - Resistive Index

S/D - Systolic: Diastolic Ratio

SD - Standard Deviation

SGA - Small for Gestational Age

TN - True negative

TP - True Positive

UA - Umbilical Artery

UAPI - Umbilical Artery Pulsatility Index

U/S - Ultra sound

VII

ABSTRACT

BACKGROUND AND OBJECTIVES:

The aims and objectives of our study was to evaluate the usefulness of middle

cerebral artery and umbilical artery Doppler indices as predictors of adverse perinatal

outcome in clinically suspected IUGR pregnancies and to establish the role of

Doppler ultrasound in the management of IUGR pregnancy.

MATERIALS AND METHODS:

The present study is a prospective study of Doppler Velocimetry of umbilical

artery and Middle cerebral artery in cases with clinical suspicion of IUGR between 31

to 40 weeks of gestation from September 2006 to September 2008. Pregnancies with

documented major congenital abnormality, multiple gestations and intrauterine death

at the time of first Doppler examination were excluded from the study. The outcome

for each pregnancy was obtained by examining the labor ward records and neonatal

intensive care unit records wherever appropriate. Findings of Doppler studies were

correlated with the following adverse Perinatal outcomes; Perinatal deaths,

Emergency CS for foetal distress, Low Apgar score (5 min Apgar <7), and admission

to NICU for complications of low birth weight. Pregnancy outcome was considered to

be Uneventful or Favourable when the above complications were absent.

The Umbilical artery Pulsatility index and the Middle cerebral artery

pulsatility index for the corresponding gestational age were compared with the

reference values. The Umbilical artery Pulsatility index was considered abnormal if

the value was above the 95th percentile of previously published values for gestational

age. The Middle cerebral artery pulsatility index was considered abnormal if the value

IX

was below the 5th percentile of previously published values for gestational age. A

single cut off value (1.08) was used for Cerebroplacental Ratio (MCA PI/UA PI),

above which the cerebroplacental ratio was considered normal and below which it

was considered abnormal.

RESULTS:

Acceptable wave forms were obtained from MCA and UA in all these cases.

All the cases were followed up for the perinatal outcome. Cerebroplacental ratio had

higher sensitivity (95.6%) and NPV (95.8%) than UAPI (Sensitivity 73.9%, PPV

94.4%) and MCA PI (Sensitivity 91.3% , PPV 70%) , UAPI had higher specificity

(96.2%) and PPV (94.4%) compared to cerebroplacental ration (Specificity 85.1%,

PPV 84.6% ) and MCAPI (Specificity 66.6%, PPV 70%).

Diagnostic accuracy of Cerebroplacental ratio (Accuracy=90%) was better

than UAPI (Accuracy=86%) and MCAPI (Accuracy=78%) in predicting adverse

outcomes.

CONCLUSION:

In suspected IUGR pregnancy, both Cerebroplacental ratio and Umbilical

artery PI are strong predictors of adverse perinatal outcome. Cerebroplacental ratio is

most sensitive and Umbilical artery PI is most specific index in predicting adverse

outcome. Absent or reversed end diastolic flow in an umbilical artery is an ominous

finding associated with major adverse perinatal outcome and mortality.

KEY WORDS: - Intrauterine growth retardation; Umbilical artery Doppler, Middle

cerebral artery Doppler; Fetal Doppler; Cerebro-placental Ratio;

X

TABLE OF CONTENTS

Page No.

1. Introduction 1 - 3

2. Objectives 4

3. Review of literature 5 - 38

4. Methodology 39 - 43

5. Results 44 - 56

6. Discussion 57 - 63

7. Conclusion 64

8. Summary 65 - 66

9. Bibliography 67 - 79

10. Annexure 80 - 85

* * * * *

XI

LIST OF TABLES

Sl.

No. Tables

Page

No.

1. Maternal complications of study group 44

2. Distribution Characteristics of Placental Maturity 45

3. Amniotic Fluid distribution in the study group 46

4. Gestational Age Distribution in study group 47

5. Pregnancy Outcome in the study group 48

6. Adverse Outcomes in the study group 49

7. Spectral Characteristics of Umbilical Artery 50

8. Performance Characteristics of Doppler Indices 51

XII

LIST OF FIGURES

Sl. No. Figures

Page

No.

1 Schematic Diagram showing Placental circulation 19

2 Schematic Diagram showing Fetal circulation 21

3 Normal Umbilical Artery Flow at 32 weeks Gestational Age 34

4 Normal Middle Cerebral Artery Flow at 32 weeks Gestational Age 34

5 Normal Umbilical Artery Flow at 34 weeks Gestation l Age 35






11 Philips Enviser CHD 41

12 Decreased Diastolic Flow in Umbilical Artery 54

13 Increased Diastolic Flow in Middle Cerebral Artery - “Brain Sparing Effect” in the same patient 54

14 Absent Diastolic Flow in Umbilical Artery 55


16 Reversed Diastolic Flow in Umbilical Artery 56


XIII

LIST OF GRAPHS

Sl. No. Graphs

Page

No.

1. Distribution of Normal UAPI with Gestation age 38

2. Distribution of normal MCA PI with gestational age 38

3. Maternal complications of study group 44

4. Distribution Characteristics of Placental Maturity 45

5. Amniotic Fluid distribution in the study group 46

6. Gestational Age Distribution in study group 47

7. Pregnancy Outcome in the study group 48

8. Adverse Outcomes in the study group 49

9. Spectral Characteristics of Umbilical Artery 50

10. Performance Characteristics of Doppler Indices 52

11. Distribution of UA PI Values with gestation for pregnancies

with adverse outcome.

53

12. Distribution of MCA PI Values with gestation for pregnancies

with adverse outcome

53

XIV

Introduction

INTRODUCTION

Intrauterine growth retardation (IUGR) is a common complication of

pregnancy which is most commonly associated with a failure of normal placental

invasion and development. IUGR is associated with an increased risk of perinatal

mortality, morbidity and impaired neurodevelopment1, 2, 3. The correct detection of the

compromised IUGR fetus to allow timely intervention is a main objective of antenatal

care.

Ultrasonographic (US) biometry helps to identify a heterogeneous group of

small–for–gestational age fetuses that include fetuses with IUGR, fetuses with small

constitution, and fetuses with appropriate growth (misdiagnosed as small). Not all

small for gestational age babies suffer from IUGR and its associated risks.

Doppler ultrasound allows a noninvasive assessment of fetal haemodynamics 4,5.

Doppler investigation of the umbilical arteries provides information concerning

perfusion of the fetoplacental circulation, while Doppler study of fetal vessels detects

the haemodynamic rearrangements that occur in response to fetal hypoxia.

Umbilical artery (UA) Doppler velocimetry is the most rigorously evaluated

test among the noninvasive tests of fetal well being 6. Several authors have

reported a low end diastolic velocity in the umbilical artery, a consequence of high

flow resistance in capillaries of the terminal villi. A metaanalysis of randomized

controlled trials of UA Doppler velocimetry in high risk pregnancies (mainly

pregnancies with associated pregnancy induced hypertension and suspected IUGR)

demonstrated that its use was associated with a trend towards reduction of perinatal

mortality 7.

1

In response to prolonged fetal hypoxic stress, circulatory adaptation occurs,

resulting in redistribution of the cardiac output to provide a constant oxygen supply to

the brain and other essential organs (i.e., heart and adrenal glands)8,9. This

compensatory adjustment, on which the brain sparing effect 10 is based, associated

with a rise in diastolic velocities in Doppler cerebral artery waveforms. This rise is

considered a manifestation of cerebral vasodilatation, causing a decrease in Doppler

indices such as the pulsatility index 11,12. At cordocentesis , a significant correlation

has been observed between hypoxemia in fetuses with IUGR and abnormal

middle cerebral artery(MCA) pulsatility index (PI.).

Recent studies indicate that the cerebroplacental ratio of pulsatility

index of MCA and UA is the most sensitive Doppler index for predicting

perinatal outcome in fetuses with IUGR 13,14

In the majority of the severely growth retarded fetuses, sequential

deterioration of arterial and venous Doppler precedes biophysical profile score

deterioration. At least one third of fetuses show early signs of circulatory deregulation

1 week before biophysical profile deterioration, and in most cases, Doppler

deterioration preceded biophysical profile deterioration by 1 day 15. This indicates the

significance of Doppler study in these patients for early detection of fetal

compromise.

Differences in study design, including the criteria for patient selection, the

definition of adverse outcomes, different cut off levels between normal and

abnormal test results makes direct comparison difficult.

Our study was an effort at establishing the role of UA and MCA Doppler

Ultrasound in predicting adverse perinatal out come in the clinically suspected

2

Pregnancies and to determine the role of Doppler velocimetry in clinical management

of such pregnancies.

3

Objectives

AIMS AND OBJECTIVES

1) To evaluate the role of Doppler ultrasonography in predicting the adverse

perinatal outcome in IUGR pregnancies using umbilical and middle cerebral

artery Doppler indices.

2) To establish the role of Doppler Ultrasonography in the management of an

IUGR pregnancy

4

Review of literature

REVIEW OF LITERATURE

Doppler ultrasound provides a unique, non invasive and safe method of

studying blood flow characteristics in both the fetoplacental and uteroplacental

circulations that is being used in clinical evaluation of high risk pregnancies. The

growing availability of Doppler equipment in the mid to late 1980s led to an

outpouring of studies examining the use of this technique in pregnant women.

Many of these studies assessed the potential value of Doppler study of various

fetal vessels like, abdominal aorta, ductus venosus, middle cerebral artery and

umbilical arteries to assess the fetal haemodynamics in a clinically suspected IUGR.

In a study, perinatal indicators of fetal compromise were assessed according to

the results of continuous-wave Doppler umbilical velocimetry for 172 patients at risk

for intrauterine growth retardation (IUGR). They found that the last Doppler study

before delivery was abnormal in 48.8% of the growth-retarded infants but in only

13.2% of the infants without evidence of IUGR. Furthermore, in the growth-retarded

group, early delivery, reduced birth weight, decreased amniotic fluid at birth,

admission to the neonatal intensive care unit, neonatal complications associated with

IUGR, and a prolonged hospital stay were observed more frequently in those who

had an abnormal ratio than in those with a normal ratio. The sensitivity of the

systolic/diastolic ratio for an adverse perinatal outcome (operative delivery for fetal

distress, neonatal morbidity associated with IUGR, and/or perinatal death) was

significantly better for the infants with IUGR (66.7%) than for the infants without

IUGR (27.8%; P< .05). The predictive value of an abnormal ratio was also higher for

the pregnancies complicated with IUGR (57.1%) than for those without IUGR

(29.4%), but not to a statistically significant degree. These data suggest that

5

Doppler umbilical velocimetry studies are valuable in identifying those growth-

retarded fetuses at increased risk for an adverse perinatal outcome16.

In a study using Doppler U/S, flow velocity wave forms in the middle cerebral

artery were studied. In growth retarded fetuses pulsatility index in MCA was

significantly reduced compared with normal pregnancy suggesting participation of

MCA in a brain sparing effect in the presence of clinical fetal hypoxia17.

In a study of fetal middle cerebral artery in 81 small-for-gestational age

fetuses (SGA) using color flow imaging and pulsed Doppler studies, Impedance to

flow (pulsatility index; PI) was significantly lower, and mean blood velocity was

significantly higher, than the respective reference ranges with gestation. Fetal blood

sampling by cordocentesis was performed in all SGA fetuses and a significant

quadratic relation was found between fetal hypoxemia and the degree of reduction in

the PI of flow velocity waveforms (FVWs) from the fetal middle cerebral artery. They

concluded that maximum reduction in PI is reached when the fetal PO2 is 2-4 SD

below the normal mean for gestation and when the oxygen deficit is greater there is a

tendency for the PI to raise, presumably reflecting the development of brain edema18.

In a study the changes in fetal Doppler parameters with advancing gestation

was studied. Furthermore, they examined the alterations in fetal haemodynamics in

relation to fetal blood oxygen tension in samples obtained by cordocentesis from

small for gestational age (SGA) fetuses. They found that in SGA fetuses, increased

downstream impedance to flow in the umbilical artery, as demonstrated by the

absence of end-diastolic frequencies in the FVWs, is associated with fetal hypoxia

which presumably reflects the underlying derangement of placental structure and

function. The impedance to flow and mean blood velocity were also measured in

6

FVWs from the descending thoracic aorta and common carotid artery, obtained by

pulsed Doppler ultrasound, and from the middle cerebral and renal arteries obtained

by color flow imaging. There were significant correlations between the degree of fetal

hypoxia and alterations in Doppler parameters, which were compatible with the brain

sparing effect. Thus, in fetal hypoxia impedance to flow in the common carotid and

middle cerebral arteries was decreased, whereas impedance in the aorta and renal

artery was increased. They also found that there were simultaneous alterations in the

mean blood velocity in the opposite direction to those in impedance19.

In a study of 45 normal-growth and 45growth-retarded fetuses between 30-

41weeks gestation, velocity recordings were obtained from the middle cerebral artery

and umbilical artery to calculate the ratio between the two pulsatility indices. The

cerebral - umbilical Doppler ratio is usually constant during the last 10 weeks of

gestation. Therefore, a single cutoff value (1.08) was used, above which velocimetry

was considered normal and below which it was considered abnormal. The cerebral-

umbilical Doppler ratio provided a better predictor of small for gestational age

newborns and adverse perinatal outcome than either the middle cerebral artery or

umbilical artery alone. In fact, in predicting those newborns who were small for

gestational age, the cerebral-umbilical ratio had a 70% diagnostic accuracy [(true

positive + true negative)/total number of cases], compared with 54.4% for the middle

cerebral artery and 65.5% for the umbilical artery. The results were more encouraging

for prediction of adverse perinatal outcome; diagnostic accuracy for the cerebral-

umbilical Doppler ratio was 90%, compared with 78.8% for the middle cerebral artery

and 83.3% for the umbilical artery12.

In a study blood flow velocity waveforms were recorded from different

vascular districts including umbilical artery, descending aorta, renal artery, internal

7

carotid artery and middle cerebral artery in a population of 120 small for gestational

age fetuses free from structural and chromosomal abnormalities. The pulsatility index

from each vessel as well as the ratios between the pulsatility indices from peripheral

and cerebral vessels were calculated and related to perinatal outcome. They found that

the pulsatility index of middle cerebral artery resulted the most efficient measurement

to predict the development of perinatal adverse outcome when each vessel was

considered singularly, however, better results were achieved when the ratios between

pulsatility indices were related to perinatal outcome; This is most evident for the ratio

between the pulsatility indices of umbilical artery and middle cerebral artery

suggesting the usefulness of this ratio in differentiating small for gestational age

fetuses at risk of unfavorable outcome20.

In a study of out come of Doppler velocimetry of the umbilical artery in three

groups of pregnancies: Those with the positive end diastolic velocities (PEDV: n=

214), absent end diastolic velocities (AEDV: n = 178) and reversed end diastolic

velocity (REDV: n = 67), pregnancies complicated by IUGR had high risk of

developing absent or reversed end diastolic flow velocity waveforms (odd ratios 3.1).

Pregnancies complicated by both IUGR and hypertension had an even higher risk

(OR= 7.4). The over all perinatal mortality rate was 28%. Significantly more neonates

in the AEDV flow group needed admittance to the NICU, PEDV group 60%, AEDV

group 96%, REDV Group 98% 21.

In a study, fetal Doppler indices, in particular ratios that include measurements

obtained from the cerebral circulation help in the recognition of the small fetus that is

growth-retarded. At term, evidence of fetal hemodynamic redistribution may exist in

the presence of a normal umbilical artery PI. Fetal Doppler indices provide

information that is not readily obtained from more conventional tests of fetal well-

8

being. It therefore has an important role to play in the management of the growth-

retarded fetus22.

In a study, Arbielle and coworkers found that the cerebral-placental ratio

constant during the pregnancy during the last 10 weeks of gestation and suggested 1

as the cut off value; they considered all values below 1 as abnormal 23.

In a study 71 high-risk fetuses with weekly UA and MCA Doppler US

examinations until delivery were studied. They found that in 15.5% (11 of 71) of

fetuses, there was perinatal mortality or major morbidity, including major intracranial

hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, and major

neurological handicap (follow-up data in 24 cases and up to only 2 years of age). By

using the last Doppler US result for analysis, the UA/MCA resistance index ratio,

compared with the UA systolic-to-diastolic ratio, was more sensitive (75% vs. 64%)

but less specific (60% vs. 74%). They concluded that UA Doppler US was a better

predictor for each of the individual adverse outcomes when separate analyses were

performed24.

In a study vascular resistances of various fetal areas were assessed by Doppler

ultrasound. The PI, RI and S/D indices are measured on the cerebral, renal, aortic and

umbilical Doppler spectrum. Ratios of these indices based on the comparison of the

cerebral (Rc) and the umbilical (Rp) resistances, or carotid (Rcc) and umbilical

resistances, or cerebral (Rc) and aortic (Rao) resistances (Rc/Rp or Rp/Rcc, or

Rc/Rao), measure the flow redistribution between the placenta and brain. They found

that the umbilical resistance indices, when greater than the upper limit of the normal

range (>2 SD) are frequently associated with IUGR. (Sensitivity is about 65 to 70%).

Absent end diastolic flow is most of the time associated with severe IUGR and

9

hypoxia and poor fetal outcome. A fairly good correlation was found between the

existence of significantly decreased (<2 SD) cerebral resistance and the development

of post asphyxial encephalopathy in the neonate (Specificity 75% and Sensitivity

87%). The earliest detectors of IUGR and hypoxia are the cerebral-umbilical,

cerebral-carotid, or cerebral-aortic ratios (Sensitivity 85% and Specificity 90%).

When used as predictor of poor perinatal outcome in growth retarded fetuses, the

cerebral umbilical ratio shows a sensitivity of 90% compared with 78% of the middle

cerebral artery, and 83% for the umbilical artery indices. Changes of this ratio were

well correlated with the fetal PO2 changes25.

In a study two hundred ninety-three small–for–gestational age fetuses (24–39

weeks at recruitment and US-estimated weight or abdominal circumference below

10th percentile) were prospectively examined with Doppler US of the UA, MCA, and

RA. Clinicians were blinded to MCA and RA Doppler measurements. Seventy-six

fetuses (25.9%) had at least one major or minor adverse perinatal outcome. Major

outcomes included stillbirth, neonatal death, neurological complication, and

necrotizing enterocolitis. The MCA pulsatility index (PI), compared with the UA PI

and RA PI, was more sensitive (72.4% vs. 44.7% and 8.3%) but less specific (58.1%

vs. 86.6% and 92.6%) in predicting adverse outcome. The UA PI had the highest

positive likelihood ratio (ratio, 3.3); the MCA PI had the lowest negative likelihood

ratio (ratio, 0.48). When gestational age at the first Doppler US examination was less

than 32 weeks, the MCA PI had a sensitivity of 95.5% and negative predictive value

of 97.7% for major adverse outcome (negative likelihood ratio, 0.10). They concluded

that in suspected IUGR, an abnormal UA PI is a better predictor of adverse perinatal

outcome than an abnormal MCA or RA PI. While, a normal MCA PI may help to

10

identify fetuses without major adverse perinatal outcome, especially before 32 weeks

gestational age26.

In a study 120 random pregnancies were screened at 20, 28 and 34 weeks of

gestation. Pregnancies with a normal outcome were used for calculating the normal

range of various indices and for testing the specificity and negative predictive value

(NPV) of the study. Those pregnancies with an abnormal outcome (PIH and SGA

babies) were used for calculating the sensitivity and positive predictive value (PPV)

of the study. In normal pregnancies, the flow velocity waveforms (FVWs) showed a

good diastolic flow and fall in indices as pregnancy progressed. A low diastolic flow

and high indices characterized the pregnancies with abnormal outcomes. The uterine

artery had a better sensitivity and specificity as compared to the umbilical artery.

Among the various uterine waveform parameters, the diastolic notch had the highest

sensitivity and specificity. Among the umbilical indices, the PI had the highest

sensitivity and specificity27.

In a study umbilical artery and middle cerebral artery waveforms were studied

in structurally normal fetuses at 35 or more weeks of gestation. Fetuses with

aneuploidy and/or major structural abnormalities were excluded. Umbilical artery and

middle cerebral artery (MCA) Doppler waveforms were recorded and considered

abnormal if above 95th or below 5th percentiles, respectively. Amniotic fluid was

considered reduced if the maximum vertical cord-free pool was < 2 cm. The placenta

was considered mature if the Grannum grade was II or III. The head circumference

(HC)/abdominal circumference (AC) ratio was considered abnormal if > 95th

percentile for gestation. Fetal growth, amniotic fluid, biophysical profile score and

umbilical artery Doppler were used to advise the referring obstetrician about fetal

well-being and he/she independently decided both the timing and mode of delivery.

11

Forty-seven fetuses fulfilled the entry criteria. Thirty-four (72%) demonstrated normal

umbilical artery Doppler waveforms. Sixteen (34%) demonstrated middle cerebral

artery redistribution, of which nine (56%) had normal umbilical artery Doppler

waveforms. MCA blood flow redistribution was associated with an increased

incidence of cesarean delivery and need for neonatal admission. Of all gray-scale

parameters, an elevated HC/AC ratio has the strongest association with MCA blood

flow redistribution (15/16 vs. 1/31; P < 0.01). They concluded that MCA Doppler

may be a useful tool to assess the health of small fetuses in the late third trimester.

Redistribution may occur in the presence of normal umbilical artery Doppler and

should be suspected when the HC/AC ratio is elevated28.

In a study Doppler flow waveforms of umbilical artery, middle cerebral artery

and thoracic aorta were obtained from 100 pregnant women with intrauterine growth

restricted fetuses.The pregnancies were grouped according to the umbilical artery

Doppler results. There were 29, 30 and 41 fetuses with normal and high PI (pulsatility

index), and absent end-diastolic velocity (AEDV) in the umbilical artery respectively.

Birth weight and umbilical vein pH at birth significantly decreased and perinatal

mortality rates significantly increased with the worsening of the diastolic flow in the

umbilical artery (p<0.01). They found that increased umbilical artery PI was

significantly associated with increased thoracic aorta PI and decreased middle

cerebral artery PI (r=0.75 and −0.55, p<0.01 respectively). Perinatal mortality due to

fetal asphyxia in fetuses with AEDV in the umbilical artery and in both the umbilical

artery and thoracic aorta was 39.5% and 50% respectively29.

In prospective study performed to determine if the ratio of the middle cerebral

artery (MCA) S/D ratio (ratio of peak systolic blood flow velocity to diastolic

velocity) to the umbilical artery (UA) S/D ratio (MCA/UA S/D ratio) predicts the

12

degree of neonatal morbidity in fetuses suspected of having IUGR. They studied Sixty

one fetuses identified prospectively by sonography as having an estimated fetal

weight below the 10th percentile for gestational age. They found that adverse perinatal

outcome like respiratory distress syndrome and intracranial hemorrhage were not

associated with abnormal Doppler findings after correction for gestational age. The

interval between the abnormal Doppler examination and delivery (p < 0.001) and the

occurrence of fetal distress requiring cesarean section (p < 0.001) were significantly

related to the severity of Doppler findings. They concluded that in fetuses with

suspected IUGR, abnormal MCA/UA S/D ratios are strongly associated with low

gestational age at delivery, low birth weight, and low UA pH. Abnormal MCA/UA

S/D ratios are also significantly associated with shorter interval to delivery and the

need for emergent delivery30.

In a study, two hundred and thirty-one pregnancies of singleton pregnancy of

birth weight < 10th centile, without severe maternal complications and fetal anomalies

on the sonogram with normal umbilical artery Doppler and complete follow-up. At

the first antenatal sonogram classifying the fetus as SGA, Doppler analysis of the

uterine and middle cerebral arteries was performed and amniotic fluid volume was

assessed. Outcome variables included adverse perinatal outcome (perinatal death,

severe morbidity) and emergency cesarean section for fetal distress. Logistic

regression demonstrated that abnormal velocimetry of the uterine arteries and fetal

middle cerebral arteries were independently correlated with the occurrence of

Cesarean section. They concluded that SGA fetuses with normal umbilical artery

Doppler waveforms and abnormal uterine arteries and fetal middle cerebral artery

waveforms have an increased risk of developing distress and being delivered by

emergency Cesarean section. Particularly when both uterine and fetal cerebral

13

waveforms are altered at the same time, the risk is exceedingly high (86%) and

delivery as soon as fetal maturity is achieved seems advisable. On the other hand,

when both vessels have normal waveforms, the chances of fetal distress are small

(4%) and expectant management31

In a Retrospective study of Doppler velocimetry of 578 singleton pregnancies

with diagnosis of intrauterine growth restriction (IUGR, four subsets were formed:

normal umbilical artery pulsatility index (NUAPI; 334 fetuses); increased pulsatility

index but with preserved diastolic flow (abnormal umbilical artery pulsatility index

AUAPI; 137 fetuses); absent end-diastolic flow (AEDF; 70 fetuses); reversed end-

diastolic flow (RF; 37 fetuses). Fetal biometry, amniotic fluid and fetal-maternal

Doppler velocimetry were evaluated in all patients, with biophysical profile and

routine non-stress test, when indicated. The following outcomes were examined:

mean gestational age at delivery, number of preterm deliveries (< 34 weeks), mean

neonatal weight, Apgar score at 5 min < 7, prenatal and neonatal deaths (within the

first 28 days of life), admission to the NICU and number of days spent after birth in

hospital. Neonatal morbidity was analyzed, including respiratory distress syndrome

(RDS), intraventricular hemorrhage (IVH, grade 2-3), necrotizing enterocolitis (NEC)

and retinopathy of prematurity. They concluded that a strict correlation exists between

abnormal umbilical Doppler velocimetry and an increased incidence of perinatal

complications in IUGR fetuses32.

In a study absent or reverse end-diastolic flow (Doppler II/III) in umbilical

artery was correlated with poor perinatal outcome, particularly in intrauterine growth

restricted (IUGR) fetuses. They also studied the short- and long-term morbidity and

mortality among these children. Sixty-nine IUGR fetuses with umbilical Doppler

II/III were divided into three groups; Group 1, severe early IUGR, no therapeutic

14

intervention (n = 7); Group 2, fetuses with pathological biophysical profile,

immediate delivery (n = 35); Group 3, fetuses for which expectant management had

been decided (n = 27). There results were, in Group 1, stillbirth was observed after a

mean delay of 6.3 days. Group 2 delivered at an average of 31.6 weeks and two died

in the neonatal period (6%). In Group 3 after a mean delay of 8 days, average

gestational age at delivery was 31.7 weeks; two intrauterine and four perinatal deaths

were observed (22%). Long-term follow-up revealed no sequelae in 25/31 (81%) and

15/18 (83%), and major handicap occurred in 1 (3%) and 2 patients (11%),

respectively, for Groups 2 and 3. They concluded that fetal mortality was observed in

22% of this high risk group. After a mean period of follow-up of 5 years, 82% of

infants showed no sequelae. According to their management protocols IUGR

associated with umbilical Doppler II or III does not show any benefit from an

expectant management in term of long-term morbidity33.

In a study, 70 pregnant women with growth-restricted fetuses confirmed by

ultrasound were followed up with Doppler studies of the umbilical artery. The study

group consisted of 35 women, where the Doppler waveform in the umbilical

artery was compromised (either absent end diastolic flow [AEDF] or reversed end

diastolic flow [REDF]). These were compared with an equal number of controls,

where growth- restricted fetuses had normal Doppler waveforms. Outcome measures

were evaluated in both groups and analyzed. The periods Of gestation at delivery

were 27.2 +/- 3.5 weeks in group 1 and 37 +/- 3.3 Weeks in-group II, respectively.

Perinatal morbidity and mortality was significantly increased in the group with

compromised umbilical artery blood group. Birth weight in group I was 742 +/-

126 grams and in group II was 680 +/- 259 grams. This difference was

statistically significant (P=0.0001). In comparison to AEDF, REDF fetuses had more

15

morbidity. Perinatal mortality was also significantly increased in this group

(P=0.001). They concluded that Umbilical artery Doppler should be used in the

management of growth-restricted fetuses. In those fetuses in normal Doppler,

pregnancy can be prolonged. REDF is an indication for termination of pregnancy34.

In a retrospective cohort study of 121 singleton pregnancies with IUGR

(birth weight less the 5th percentile for gestation) excluding twins or fetuses with

aneuploidy and congenital malformations was conducted. Abnormal antenatal

testing such as NST which was non-reactive or with late decelerations: BPP <6

and abnormal Doppler as umbilical artery with absent and reversed diastolic

flow. The outcomes studied included: umbilical artery pH <7, respiratory distress

syndrome, periventricular leukomalacia, grades 3-4 intraventricular hemorrhage,

perinatal mortality, necrotizing enterocolitis and a composite of at least one

adverse outcome .statistical analysis included bivariate and multivariable

techniques. Of the testing modalities compared only abnormal Doppler

significantly predicted respiratory distress and composite of adverse outcome.

They concluded that in cases of IUGR the presence of abnormal Doppler is the

best predictor of adverse perinatal outcome35.

16

Anatomy of fetoplacental and uteroplacental circulation

Fetoplacental circulation 36 37

During fetal life oxygenation is carried out in the placenta. The fetal

surface of the placenta is covered by the transparent amnion, beneath which

the fetal chorionic vessels course.

Deoxygenated or venous like fetal blood flows to the placenta through the two

umbilical arteries. When the umbilical cord joins the placenta, the umbilical vessels

branch repeatedly beneath the amnion and again within the dividing villi, finally

forming capillary networks in the terminal divisions. Blood with significantly higher

oxygen content returns from the placenta to the fetus through a single umbilical vein.

The branches of the umbilical vessels that traverse along the foetal surface of the

placenta in the chorionic plate are referred to as the placental surface or chorionic

vessels. These vessels are responsive to vasoactive substances, but anatomically,

morphologically, histologically, and functionally, they are unique. The chorionic

arteries always cross over the chorionic veins. Identification of chorionic artery and

vein is most readily recognized by this interesting relationship, but they are difficult to

distinguish by histological criteria. In 65 percent of placentas, the chorionic arteries

form a fine network supplying the cotyledons .The remaining 35 percent of arteries

radiate to the edge of the placenta without narrowing. Both are end arteries, supplying

one cotyledon as each branch turns downward to pierce the chorionic plate.

The truncal arteries are the perforating branches of the surface arteries that

pass through the chorionic plate. Each truncal artery supplies one cotyledon. There is

a decrease in the smooth muscle of the vessel wall and an increase in the calibre of the

vessel as it penetrates through the chorionic plate. The loss in smooth muscle

17

continues as the truncal arteries branch into the rami, and the same is true of the vein

walls.

Materno placental circulation 36, 37

Maternal blood enters through the basal plate and is driven high up

towards the chorionic plate by maternal arterial pressure before lateral

dispersion occurs. After bathing the external micro villous surface of chorionic villi

the maternal blood drains back through venous orifices in the basal plate and enters

the uterine veins, maternal blood traverses the placenta randomly without preformed

channels, propelled by maternal arterial pressure. The Processes of trophoblast

invasion of the spiral arteries create low-resistance uteroplacental vessels, which can

accommodate the massive increase in uterine perfusion over the course of gestation.

Generally, the spiral arteries are perpendicular to, but the veins are parallel to,

the uterine wall, an arrangement that facilitates closure of the veins during a uterine

contraction and prevents squeezing of essential maternal blood from the

intervillous space. The number of arterial openings in to the intervillous space

becomes gradually reduced by cytotrophoblast invasion.

18

Fig 1: Schematic Diagram showing Placental circulation

Fetal circulation 36, 37

Oxygen and nutrition materials required for fetal growth and maturation

are delivered to the fetus from the placenta by the single umbilical vein. The

umbilical vein enters the fetus at umbilicus and runs along the free margin of the

falciform ligament of the liver. The vein then divides in to the ductus venosus

and the portal sinus. The ductus venosus is the major branch of the umbilical

vein and traverses the liver to enter the inferior venacava directly. Portal sinus

carries blood to the hepatic veins primarily on the left side of the liver, the

deoxygenated blood from the liver then flows back in to the inferior venacava,

which also receives deoxygenated blood from the lower body. The well

19

oxygenated blood tends to course along the medial aspect of the inferior

venacava and the less oxygenated blood stays along the lateral vessel wall,

facilitating their shunting in to opposite sides of the heart. In contrast to

postnatal life, the ventricles of the fetal heart work in parallel, not in series.

Well –oxygenated blood enters the left ventricle, which supplies the

heart and brain, and less oxygenated blood enters the right ventricle, which

supplies the rest of the body. Once the inferior venacava blood enters the right

atrium, the configuration of the upper interatrial septum, called the crista

dividens, is such that it preferentially shunts the well oxygenated blood from

the medial side of the inferior venacava and the ductus venosus through the

foramen ovale in to the left heart and then to the right heart and brain. The

less oxygenated blood coursing along the lateral wall of the inferior venacava,

less oxygenated blood from the brain and upper body through the superior

venacava, and deoxygenated blood from the heart through the coronary sinus

enters the right atrium and is deflected through the tricuspid valve to the right

ventricle. As a result of this blood in the right ventricle is 15-20% less

saturated than in left ventricle. Almost 90% of blood from the right ventricle

is shunted through the ductus arteriosus to the descending aorta The high

pulmonary vascular resistance and the comparatively lower resistance in the

ductus arteriosus and the umbilical-placental vasculature ensures that only 15%

of the right ventricular output goes to the lungs. Thus, one third of the blood

passing through the ductus arteriosus is delivered to the body. The remaining right

ventricular output returns to the placenta through the two hypogastric arteries,

which distally become the umbilical arteries. In the placenta, this blood picks

20

up oxygen and other nutrients and is then recirculated back through the

umbilical vein.

Fig 2: Schematic Diagram showing Fetal circulation

21

INTRAUTERINE GROWTH RESTRICTION

DEFINITION

Intrauterine growth retardation has been defined in a variety of ways

by different authors. Intrauterine growth retardation is a fetal growth disorder

most commonly defined on the basis of a weight below the 10th percentile for

the corresponding gestational age .Small for gestational age and IUGR has been used

interchangeably, but now IUGR is restricted for the clinical circumstance of a fetus

that is underachieving its growth potential38.

Intrauterine growth restriction is associated with increased risk of perinatal

morbidity and mortality. Growth restricted fetus have 4-8 times mortality when

compared to that of non IUGR fetuses. One half of surviving growth

restricted infants suffer serious short or long term morbidity including

meconium aspiration pneumonia and metabolic disorders39,40 .

CAUSES

IUGR has many causes including placental insufficiency which may be

primary or secondary to maternal disorder such as hypertension, collagen

vascular disease, poor nutrition, drug and alcohol abuse , fetal chromosomal

anomalies (trisomy 13 and 18) and fetal infections (cytomegalo virus and

toxoplasma)41,42, placental or cord abnormalities which include placental

infraction, chorioangioma, marginal or velamentous cord insertion, circumvallete

placenta, or placenta previa. primary placental insufficiency is the most common

cause of IUGR.

22

IUGR has been categorized as asymmetrical where growth restricted

fetal abdomen is disproportionately small in relation with head and limbs and

symmetrical where fetuses are proportionately small in size. The former is

more common variety, is the pattern expected in the most cases of primary

or secondary to placental insufficiency. The latter is seen in cases resulting

from an early insult. There is however, considerable overlap between these two

groups.

PATHOPHYSIOLOGY

IUGR is primarily the result of disturbances in placental vascular

development 43.In early pregnancy miscarriage may result from inhibited angiogenesis

and poor placental adherence. Later in gestation, inadequate trophoblastic invasion in

to maternal spiral and radial arteries leads to the failure of establishment of a low

resistance circuit that is a key to further fetal growth. The fetal response to

uteroplacental insufficiency (UPI) can be categorized in to early and late

cardiovascular adaptations that are relevant to sonographic assessment of fetal status.

Early adaptation is characterized by changes in blood flow to favor nutrient and

oxygen distribution to essential organs, especially the brain. Umbilical venous volume

is reduced in early stages of UPI, leading to oligohydramnios due to decreased renal

perfusion 44. This leads to greater diversion of the relatively nutrient oxygen rich

umbilical venous blood through the ductus venosus away from the liver and to the

fetal heart; through the foramen ovale, this blood then enters the left side of the heart,

and from there, moves on to the coronary and cerebral circulations 45. Facilitating this

shunting is an elevation in right ventricular after load owing to the high resistance of

the pulmonary vasculature as well as the rising placental resistance. A reduction in

left ventricular after load occurs as well owing to the drop in cerebral vascular

23

resistance.46, 47, 48,. Late changes occur with progressive UPI and increasing placental

resistance with development of oligohydramnios. Cardiac output declines owing to

the rising after load, resulting in reduced forward flow. As a result, the ability to

handle preload is also significantly diminished, leading to elevated central venous

pressure and inhibition in forward venous flow49,50 The final stage is global

myocardial dysfunction and dilatation51. Holosystolic tricuspid insufficiency and

spontaneous fetal heart rate deceleration herald impending death 52.

SHORT AND LONG TERM SEQUELAE

Significant immediate complications include increased mortality, transient

tachypnoea of newborn, hypothermia, hypoglycemia, polycythemia, hyperviscosity,

hyperbilirubinemia and impaired immune function53-57, Long term sequelae in

premature infants are increased risk for neurodevelopmental abnormalities and

cognitive impairment. Term IUGR babies are also at risk for learning difficulties,

behavioral problems and worse school performance58, 59

DIAGNOSIS

Sonographic diagnosis of IUGR

The definition of IUGR as a weight below the 10th percentile for

gestational age Suggests a straight forward method for diagnosis by obstetric

sonography: if the sonographically estimated fetal weight falls below the 10th

percentile for gestational age. Calculating the weight percentile requires three

steps60,61,62 First - a gestational age is assigned to the fetus., Second- fetal weight is

estimated, Third- the weight percentile is calculated from the estimated weight

and gestational age.

24

Once fetal age has been firmly established, the determination of fetal growth

becomes necessary in the high risk pregnancies. Inherent in determining interval

growth is necessary for at least two temporally spaced measurements of biometric

parameters. Given that growth is continuous rather than sporadic, and that the

identification of growth is limited by the technical capability of the ultrasound

equipment used, the recommended interval between ultrasound evaluations of fetal

growth is 3 weeks, because shorter intervals increase the likely hood of a false

positive diagnosis of abnormal growth.

Additional sonographic criteria for diagnosis of IUGR are elevated head

circumference/ abdominal circumference, elevated femur length/ abdominal

circumference, presence of advanced placental grade and oligohydramnios

without rupture of membranes. Others like trans cerebellar diameter/ abdominal

circumference, fractional thigh volume measurement (three dimensional ultrasound) ,

soft tissue and subcutaneous fat estimation63,64,65

Monitoring the growth retarded fetus

A growth retarded fetus should be delivered before term if the risks

associated with remaining in utero become greater than the risks of prematurity

outside the uterus. As these risks are not static, once IUGR has been

diagnosed and a lethal cause excluded, the fetus should be monitored closely

with sonography for the remainder of the pregnancy. The appropriate timing of

follow up sonograms depends on IUGR severity and gestational age; weekly or

semi weekly scans are typically called for in cases of third trimester IUGR.

Sonographic features to be followed include fetal growth, amniotic fluid

volume, biophysical profile, and spectral Doppler waveforms. A worsening trend

25

in one or more of these, especially if the change is abrupt, should prompt

consideration of early delivery.

Doppler velocimetry

Doppler ultrasound allows a noninvasive assessment of fetal haemodynamics.

Uteroplacental insufficiency is associated with progressive worsening of placental

Resistance. Increased resistance leads to decreased velocity in the feeding arteries,

especially during diastole, and to decreased volume of blood flow through the

placenta. Disproportionate slowing of diastolic relative to systolic flow leads to

elevation of a number of Doppler indices, including the systolic/diastolic ratio and the

pulsatility index. Therefore, proposed Doppler criteria for IUGR have included

elevated systolic/diastolic ratio or pulsatility index in the fetoplacental or

uteroplacental circulation (umbilical artery, other fetal arteries, or uterine arcuate

arteries) and decreased volume flow through the umbilical vein.66-72

Doppler interrogation of the fetal arterial system provides an indirect

assessment of placental resistance, where as the fetal venous system provides an

assessment of fetal cardiac function.

Doppler imaging in monitoring growth retarded fetus

Doppler imaging is of value for monitoring the pregnancy because it

can provide indirect evidence of fetal compromise. Numerous studies support

the value of Doppler waveform indexes of the umbilical artery and perhaps of

fetal cerebral Arteries for assessing the prognosis of fetuses with IUGR. In

particular, the frequencies of caesarean section for fetal distress, admission to

neonatal care unit, and perinatal mortality are all two fold to four fold higher

26

in growth retarded fetuses with abnormal umbilical artery waveforms and with

decreased systolic to diastolic ratio 73-78. In the fetal internal carotid and middle

cerebral arteries, a decreased systolic/diastolic ratio or pulsatility index suggests

fetal hypoxia, because the fetal response to hypoxia is to decrease resistance in

the cerebral circulation in order to increase blood flow to the brain 78-82 .The

Doppler finding with the greatest impact on pregnancy management is absent

or reversed end-diastolic flow in the umbilical artery81-86. Reversed flow is an

ominous finding associated with a high mortality rate within 1-7 days if the

fetus is left in utero 88. Absent flow suggests a poor prognosis as well,

although outcome in these fetuses is not as poor as in those with reversal

flow. With either of these findings prompt delivery must be seriously

considered.

PHYSICS OF DOPPLER ULTRASONOGRAPHY

Doppler ultrasound is based on the principle of the Doppler effect, so named

for Johann Christian Doppler, who identified this occurrence in 1842.The change in

the pitch of sound of a moving object caused by a relative caused by a

relative motion between the observer and the object is known as Doppler shift

and is a consequence of Doppler phenomenon.

When the frequency of the Doppler sound emitted from a stationary

source is fixed, and its insonation angle is known, the Doppler shift can be

calculated, as it is correlated to the velocity of the relative movement between

the target and the transducer. This relation is defined by the formula:

FD = 2 fo v Cos θ/c

27

Where FD the Doppler shift, fo is the frequency of the transmitted

ultrasound, v is the velocity of the relative movement, θ is the insonation

angle, and c is the velocity of sound within the tissue89

Continuous wave Doppler ultrasonography

In continuous wave Doppler, the system features separate emitting and

receiving Transducers that are arranged in a manner that their insonation axes

intersect at a certain range determined separately for each pair of transducers.

Continuous wave Doppler determines only the velocity of the blood but not

the position of the vessel.

Pulsed wave Doppler ultrasonography

In pulsed Doppler the ultrasonic waves is emitted in a pulsatile fashion.

Between the pulses of emission the same transducer operates as a receiver for

the backscattered echoes. Because the velocity of sound is presumed to be

constant, it is possible to analyze the back scattered echo alone from a

particular range. A circuit selectively permits only those signals from that arrive

to the receiver at a given time after the transmission. This allows a precise

determination of the size if the sample volume that can be located in a

particular area. the maximum Doppler shift frequency that could be measured is

related to half of the pulse repetition frequency (Nyquist limit). Beyond this

limit, Doppler signals will be distorted (aliasing).

Color flow imaging

In color Doppler imaging (CDI) color coded pulsed Doppler information

is superimposed on a B-Mode ultrasonic image. In this method color is assigned to

28

flow direction. Customarily flow towards the transducer is red and flow away

from the transducer is blue. The structures that do not move are represented in

basic gray-scale image. The color saturation is related to the magnitude of the

frequency shift. Color flow imaging facilitates the determination of small

vessels and slow blood-flow velocity.

Color Doppler energy

Color Doppler energy (CDE) detects the energy of Doppler signals

generated from the moving blood. The information obtained is different from that

of conventional CDI. the most distinctive feature of CDE is that it is

independent of the direction of blood flow.

Doppler velocimetry

Qualitative assessment:

Doppler spectrum is as series of spectra obtained by the Doppler signal

detected by the receiving transducer which contains mixture of Doppler shift

frequencies. Flow velocity waveforms are graphical drawings that show the

relative power of each frequency component that constitutes the entire Doppler

signal. The mean flow velocity waveforms(FVW) is therefore related to three

variables: time, frequency and power. The simplest qualitative method used in

Doppler data is to decide whether flow is present or not . This can be

achieved either visually or by listening to the Doppler signals. The color flow

data can also be regarded in this sense as a qualitative method and contribute

a great deal to the detection of blood flow.

29

Quantitative method:

The measurement of the velocity, acceleration, and volume of blood

flow can be achieved with Doppler data. When the angle between the

ultrasound beam and the longitudinal axis of the vessel is known, the Doppler

frequency shift can be achieved in to velocity by the equation:

FD = 2 fo v Cos θ/c

It can be seen from the equation that as the angle of insonation approaches 90

degrees the Doppler shift frequency decreases towards zero (cos 90º =0). There fore

the Doppler measurements are considered to be reliable as long as the insonation

angle is <60 deg90. The velocity measurements most commonly used in pulsed

Doppler studies are the maximum peak systolic velocity, the highest time averaged

maximum velocity and the minimum diastolic velocity.

Semi quantitative method:

Here the relationship between the systolic and diastolic components of the

waveform is evaluated and angle dependence, which is important in quantitative

method becomes less important. Different equations have been proposed to

define the properties of Doppler spectrum, the most common obstetric

applications being the pulsatility index(PI), and the resistive index(RI)(also

pourcelot index).

PI = S -- D/A

RI = S -- D/S

S/D ratio

30

Where S is the maximum peak systolic frequency, D is the end-diastolic, and

A is the mean Doppler shift frequency during a cardiac cycle. As can be seen from

the equations, when D=0 , the resistance index irrespective of the systolic

component will always be 1, where as pulsatility index will always be >1.

consequently under such circumstances, PI will be more informative than RI.

In addition PI takes the entire waveform in to account and not just the

maximum and minimum frequencies, as does RI91 .

Umbilical Artery and Middle Cerebral Artery Doppler in Normal and IUGR

Pregnancies

Umbilical artery

The umbilical artery was the first fetal vessel to be evaluated by Doppler

velocimetry has since become the most widely investigated part of fetal

circulation. This may be because of its easy accessibility and forms a vital

component acting as a lifeline between the fetus and the placenta.

The assessment of umbilical blood flow provides information on blood

perfusion of the fetoplacental unit. End-diastolic flow is not detected in the

umbilical artery before the end of 10 weeks gestation. End diastolic flow is

first detectable from the 11th to 14th weeks, although this initial flow is

inconstant. Constant end-diastolic flow, velocities are consistently detected after 14

weeks gestation although this initial flow is inconstant or complete. The increase in

the end diastolic flow with advancing gestation is due to increase in the number of

tertiary stem villi that takes place with maturation of placenta92.Thus the systolic/

diastolic ratio and pulsatility index decreases as the pregnancy advances.

31

Middle cerebral artery

Intracranial blood flow can be visualized as early as the 7th week of

gestation. An End-diastolic flow component is consistently observed in the

middle cerebral artery starting in the 12th week. The diastolic component is

less in the early second trimester, later diastolic component increases as the

gestation advances which is attributed to the decreased impedance with

development of the brain. The typical middle cerebral artery waveform at 28 to 32

weeks is characterized by high systolic velocities and minimal diastolic velocities,

resulting in high PI values, generally greater than 1.96. During pregnancy, there is a

continuous forward flow in all cerebral arteries through out the cardiac cycle.

The PI of the MCA decreases during the latter weeks of gestation and remains

unchanged in the early neonatal life.

Umbilical and middle cerebral artery Doppler changes in IUGR

In chronic placental insufficiency which is the most common cause for

IUGR, a substantial increase in the vascular resistance of the fetoplacental unit leads

to a decrease in end-diastolic flow velocity or its absence in the FVW. Initial studies

have demonstrated a relationship between abnormal flow velocity wave forms and

decrease in the number of small stem villi, irregular branching of distal villous tree, or

reduced vascularization or maldevelopment of intermediate and tertiary villi93-97.

These changes deteriorate the transplacental oxygen transport and lead to IUGR.

The association of abnormal UA FVW and fetal hypoxemia or acidemia in

IUGR fetuses has been documented in studies utilizing cordocentesis98. This is further

supported by the finding of a significant increase in the nucleated red blood cell

counts of neonates in whom abnormal UA FVW with or without signs of

32

redistribution and IUGR were diagnosed prenatally99,100. The appearance of a reversed

end-diastolic flow velocity is the final step in the cascade of events that may lead to

intrauterine fetal death. As a consequence of the placental insufficiency, in

response to prolonged fetal hypoxic stress, circulatory adaptation occurs, the

fetus shifts its blood flow to the vital organs such as brain, heart and adrenal

glands. The increased blood flow to the brain is called “Brain Sparing Effect”.

Brain sparing effect leads to cerebral vasodilatation leading to increased

diastolic flow which is seen as decreased pulsatility index in middle cerebral

artery Doppler velocimetry.

The redistribution in hypoxemic SGA fetuses may be transitory. With

worsening of oxygen deficit, the PIs tend to rise, which may be attributable to the

development of brain edema. A transition from previously detected low vascular

impedance to a high impedance flow with reversed diastolic component may precede

intrauterine death.

Various studies shows that the cerebroplacental ratio which is the ratio

of pulsatility index of cerebral artery to the umbilical artery is more sensitive in

predicting the perinatal outcome .

33

Methodology

MATERIALS AND METHODS

Data for the study was collected from all patients of clinically suspected IUGR

pregnancies, referred to the department of Radio diagnosis, Bapuji hospital and

Chigateri hospital, attached to J.J.M. Medical College. Davangere. Study was done

for a period of two years from September 2006 to September 2008.

Women referred for antenatal Doppler were included in the study if the

following Inclusion criteria were met:

• Singleton pregnancy.

• Fetal gestational age of 30 to 40 weeks with clinically suspected intrauterine

growth retardation. (Estimated fetal weight <10th percentile for gestation)

• The gestational age was based on last menstrual period (LMP), ultrasound

biometry performed before the 20th gestational week, when the LMP is

uncertain or not known and early ultrasound before 13 weeks has not been

performed”.

• Exclusion criteria for the study included any pregnancy with

o Documented major congenital abnormality

o Multiple gestations

o Intrauterine death at the time of first Doppler examination.

Present study included a total number of 50 cases meeting the inclusion

criteria. Doppler US evaluation was performed following a detailed clinical history,

US biometry, and assessment of amniotic fluid and placental maturity. Follow up

Doppler studies were performed if clinically indicated to determine a favorable or a

worsening trend in the Doppler indices. However, only the results of the first Doppler

ultrasound were used for analysis of perinatal out come.

39

Doppler US Technique:

After ultrasound biometry assessment, all women were subjected to Doppler

studies of the umbilical artery (UA) and middle cerebral artery (MCA) serially

between 30-40 weeks. These assessments were performed by using an ultrasound

machine, the Philips Enviser CHD and a probe of 2-5MHz. the filter was set at 100

HZ. All measurements were plotted graphically in accordance with normograms

provided by the Harrington et al for Doppler indices.

The wave forms were obtained during fetal inactivity and apnea. Umbilical

artery Doppler flow velocity waveforms were obtained from a free loop of cord, and

measurements taken when a clear waveform was acquired in the absence of fetal

breathing or body movement.

For MCA Doppler US, a transverse image of the fetal head was obtained at the

level of the sphenoid bones. Color flow imaging was used to display the circle of

Willis. The MCA in the near field was insonated about 1 cm distal to its origin from

the internal carotid artery. The angle of insonation in both the cases are was less than

60deg.

The Pulsatility index (PI) was measured, and the presence or absence of end-

diastolic frequencies was noted. The PI was used as it continues to reflect changes in

resistance with progressive absence of end-diastolic frequencies or reverse flow.

40

Outcome Criteria

Doppler US results were analyzed for prediction of perinatal outcome. Outcome

variables included are:

Birth Weight (less than 10th percentile)

• Perinatal death

• Emergency CS for fetal distress

• Low APGAR score (5 min APGAR score less than 7)

• Admission to NICU for complications of Low Birth Weight.

• Pregnancy was considered to have “Adverse outcome” when any of the

following complications were present

o Perinatal death

o Emergency CS for fetal distress

o 5 minute Apgar score of less than 7

o Admission to NICU for complications of low birth weight.

Pregnancy outcome was considered to be Uneventful or Favorable when the

above complications were absent. The outcome for each pregnancy was obtained by

examining the labor ward records and neonatal intensive care unit records wherever

appropriate. The UA Pulsatility index ratios were considered abnormal if the value

was above the 95th percentile of previously published values for gestational age

22.The MCA pulsatility index was considered abnormal if the value was below the 5th

percentile of previously published values for gestational age 22.The MCA/UA PI ratio

(cerebro-placental ratio) is considered abnormal when it is less than 1.08 as given by

the Gramellini D et al 12.

42

Statistical analysis

Statistical analysis was done by using proportions. The sensitivity, specificity,

positive predictive value, negative predictive Value and diagnostic accuracy were

determined for all Doppler measurements using the following formulae.

A Sensitivity = ----- X 100 A + C D Specificity = ----- X 100 B + D A

Positive Predictive Value= -------- X 100

A + B

D Negative Predictive Value= ----------- X 100 C + D

A+D Diagnostic Accuracy = ------------- Total number of cases.

A = True positive B = False positive C = False negative D = True negative.

43

19.13

53.75

23.02

4.1

0

10

20

30

40

50

60

No.

of F

ibro

id (I

n Pe

rcen

tage

)

Normal 6-12 Weeks 12-20 weeks > 20 weeks

GRAPH IV : CLINICAL ASSESSMENT OF UTERINE SIZE

Results

RESULTS

The present study was performed during a period of 2 years from September

2006 to September 2008.

50 pregnancies with clinically suspected IUGR were evaluated with Doppler

ultrasonography. Acceptable waveforms were obtained in all the cases.

Table – 1 Maternal complications of study group

Maternal complications Percentage of cases

Pregnancy induced hypertension 42%

Anemia 20%

Gestational hypertension 6%

Out of 50 cases 42% (n=21) had pregnancy induced hypertension, 20 %

(n=10) had anemia and 3 had gestational hypertension at first Doppler examination.

Graph – 3: Maternal complications of study group

42%

20%

6%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Perc

enta

ge

Pregnancy induced hypertension Anemia Gestational hypertension

Maternal Complications

Pregnancy induced hypertension

Anemia

Gestational hypertension

44

Table -2: Distribution Characteristics of Placental Maturity

Placental grading No of Cases (%)

2 29 (58)

3 21 (42)

Total 50 (100)

In our study 58 %( n=29) had grade 2 placenta, 21 %( n=42) had grade 2

placenta.

Graph -4: Distribution Characteristics of Placental Maturity

58%

42%

0%

10%

20%

30%

40%

50%

60%

Perc

enta

ge

2 3

Placental Grading

2

3

45

Table -3: Amniotic Fluid distribution in the study group

Amniotic fluid Present Normal

Oligo 14 7

Normal 12 17

Total 26 24

46% (n=23) had oligohydramnios and 54% (n=27) had normal amniotic fluid.

Graph -5: Amniotic Fluid distribution in the study group

1412

7

17

0

2

4

6

8

10

12

14

16

18

No o

f pat

ient

s

Present Normal

Amniotic Fluid

OligoNormal

46

Table -4: Gestational Age Distribution in study group

Gestational Age in weeks No of Cases (%)

30 10

31 2

32 26

34 34

36 26

38 2

Mean gestational age at the first Doppler US examination was 34weeks +/-

4weeks (2 SD).

Graph -6: Gestational Age Distribution in study group

10

2

26

34

26

2

0

5

10

15

20

25

30

35

Per

cenr

age

30 31 32 34 36 38Gestational Age in weeks

303132343638

47

Table -5: Pregnancy Outcome in the study group

Pregnancy

outcome No of cases Percentage

Outcome No of cases Percentage

Adverse 23 46%

Uneventful 27 54%

52% (n=26) fetuses had at least one abnormal outcome, of those; some (n=12) had

more than one abnormal outcome. Remaining 24 fetuses had normal outcome.

Graph -7: Pregnancy Outcome in the study group

Pregnancy Outcome

46%

54%

AdverseUneventful

48

Table -6: Adverse Outcomes in the study group

Adverse Outcomes No of cases

Intra uterine deaths 7 (30%)

Emergency CS 13(56%)

Low Apgar score 6(26%)

Admission to NICU 14(60%)

70% of neonates (n=35) had birth weight of less than 2.5 kg. There were 7

intra uterine deaths and 43 live births. Of the 43 live births,14 neonates were

admitted to NICU for low birth weight, 6 neonates had 5 min Apgar score of less than

7 and 13 babies were born by emergency ccesaerian section for fetal distress.

Graph -8: Adverse Outcomes in the study group

30

56

26

60

0

10

20

30

40

50

60

Perc

enta

ge

Intra uterine deaths Emergency CS Low Apgar score Admission to NICU

Intra uterine deathsEmergency CSLow Apgar scoreAdmission to NICU

49

Table 7: Spectral Characteristics of Umbilical Artery

Spectral Characteristics No Of Cases IUD Mortality

Absent EDF 06 3 50%

Reversed EDF 02 2 100%

Of the7 IUDs, 2 cases had reversal of diastolic flow and 4 had absent diastolic

flow. In all cases with reversal of diastolic flow, IUD of the fetus occurred with in one

week of diagnosis.

Graph 9: Spectral Characteristics of Umbilical Artery

50%

100%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mor

talit

y

Absent EDF Reversed EDFSpectral Characteristics

Absent EDFReversed EDF

50

Table 8: Performance Characteristics of Doppler Indices

Parameters Sensitivity Specificity PPV NPV

Diagnostic

Accuracy

UAPI 73.9 96.2 94.4 81.2 86

MCAPI 91.3 66.6 70 90 78

MCAPI/

UAPI 95.6 85.1 84.6 95.8 90

Cerebroplacental ratio (MCA/UA PI Ratio was most sensitive (sensitivity

95.6%) than MCA PI sensitivity (sensitivity 91.3%) and UA PI sensitivity (sensitivity

73.9%)

Umbilical artery PI was the most specific (specificity96.2%), than

Cerebroplacental Ratio (specificity = 85.1%) and MCA PI (Specificity=66.6%)

Umbilical artery PI had highest Positive Predictive Value (PPV=94.4%) followed by

Cerebroplacental ratio (PPV=84.6%) and MCA PI (PPV=70%).

Negative Predictive Value of Cerebroplacental Ratio was 95.8% when

compared to 90% for MCA PI and 81.2% for UAPI.

Diagnostic accuracy of Cerebroplacental ratio (Accuracy=90%) was better

than MCA PI (Accuracy=78%) and UA PI (Accuracy=86%) in predicting adverse

outcomes.

51

Graph 10: Performance Characteristics of Doppler Indices

73.9

96.2 94.4

81.286

91.3

66.6 70

90

78

95.6

85.1 84.6

95.890

0

20

40

60

80

100

120

Sensitivity Specificity PPV NPV DiagnosticAccuracy

Parameters

Perc

enta

ge

UAPI

MCAPI

MCAPI/ UAPI

52

Discussion

DISCUSSION

Intrauterine growth restriction is associated with increased risk of perinatal

morbidity, mortality and impaired neurological development1-3. It is a challenge to

differentiate the fetus with pathologic growth restriction and hence at risk for perinatal

complications from constitutionally small but healthy fetus.

Doppler velocimetry is a noninvasive technique that evaluates abnormal fetal

haemodynamics that takes place in response to changes in placental resistance. A

Doppler index that reflects both of these areas can be useful for identifying fetuses

with increased placental and decreased cerebral resistance.

Umbilical artery and middle cerebral artery Doppler ultrasound clearly depicts

the information about placental resistance and the changes in the fetal

haemodynamics in response to it. Umbilical arteries Doppler reflects the

maldevelopment of the placental tertiary stem villi which increases the placental

resistance leading to growth retarded fetus. Middle cerebral artery Doppler has

enabled the confirmation of brain sparing effect in IUGR. Hence we chose the UA PI,

MCA PI and MCA PI/UA PI i.e. cerebroplacental ratio as the tool for predicting the

perinatal out come in IUGR.

We studied the Doppler index of umbilical artery only after 30th week,

because in agreement with Schulman101, Gramellini 12, we believe that it is difficult to

define normal or abnormal umbilical flow velocity before 30th week, with the

exception of absent end diastolic flow velocity after 20th week.

We studied the Doppler index of middle cerebral artery because it is the most

accessible artery to see the cerebral redistribution as it is the main branch of the

circle of Willis and carries 80% of the blood flow to the ipsilateral cerebral

hemisphere, a constant 3%–7% of cardiac output throughout gestation.

57

The MCA PI and UA PI values for the corresponding gestational age

were compared with reference values given by Harrington et al 22 normograms.

MCA PI was considered abnormal when it is less than 5th percentile for that

gestational age and UA PI was considered abnormal when it is more than 95th

percentile for the corresponding gestational age.

It is possible to use a single cut off value for cerebroplacental ratio after 30th

week because cerebral-umbilical Doppler ratio does not vary significantly between

30th and 40th weeks as reported by Waldimiroff et al11 who observed a significant

differences in cerebroplacental ratio only between weeks 26-38. After 26th week, the

statistical comparison showed no significant differences between the intervals

considered. Arbeille23 et al also found the cerebral-placental ratio constant during the

pregnancy and suggested 1 as the cut off value and all values below 1 were

considered abnormal. We considered the study of Gramellini et al12 that

cerebroplacental ratio less than 1.08 as abnormal.

We have studied about 50 pregnancies with clinical suspicion of IUGR. 70%

of neonates (n=35) had birth weight of less than 2.5 kg. There were 7 intra uterine

deaths and 43 live births. Of the 43 live births, 14 neonates were admitted to NICU, 6

neonates had 5 min Apgar score of less than 7 and 13 babies was born by emergency

caesarian section for fetal distress. Of the7 IUDs, 2 cases had reversal of diastolic

flow and 4 had absent diastolic flow. In both cases with reversal of diastolic flow,

IUD of the fetus occurred with in one week of diagnosis.

.

Umbilical artery - It was found to have low sensitivity of 73.9% when

compared to MAC PI and cerebroplacental ratio. The sensitivity was comparable with

that of Fong KW et al26 and Gramellini et al12

58

Fong K W et al

Gramellini et al

Present study

44.7%

64% sensitivity 73.9%

86.6%

90.7% specificity 96.2%

54%

72.7% PPV 94.4%

81.7%

86.7% NPV 81.2%

The specificity of the UA PI 96.2% was found to be better than other

variables. The specificity was comparable with the above mentioned studies. The UA

PI is effective to rule in the possibility of adverse perinatal out come when it is

abnormal. The Positive Predictive Value of UA PI 94.4% was more than that of MCA

PI and Cerebroplacental ratio. It indicated the likelihood of adverse perinatal outcome

in growth retarded fetus with abnormal UA PI. The positive predictive value was

higher when compared to all other studies. The negative predictive value 81.2%

obtained in our study was comparable with the above mentioned studies. This was

less than that of MCA PI and cerebroplacental ratio.

Our findings confirms the results of Fong KW et al26, Chan et al24 and

Gramellini et al12 that abnormal UAPI is associated with adverse outcome like NICU

admission for low birth weight and low apgar scores than the one with normal UA PI.

It provides the most useful information for differentiating fetuses already

compromised or likely to become compromised from those that are

noncompromised.

59

Our findings agree with Harrington et al22 that umbilical artery can be normal

in term and near term with abnormal middle cerebral artery. In our study we had 7

false negative values out of which 4 patients were term gestation and 2 were near term

gestation.

Middle cerebral artery - was found to have a sensitivity of 91.3% less than

that of cerebroplacental ratio and more than that of UA PI. The values were not

comparable with the below mentioned studies.

Fong K W et al

Gramellini et al

Present study

Sensitivity 72.4% 24%

91.3%

Specificity 58.1% 100% 66.6%

PPV 37.7% 100%

70%

NPV 85.7% 77.3%

90%

It showed specificity 66.6% lesser than the other two parameters. It agrees

with Fong et al26 that MCA PI is less specific than cerebroplacental ratio and UA PI.

The study had more number of false positive values. There are several possible

explanations for the low Specificity of the MCA pulsatility index for adverse perinatal

outcome. Among several published normograms for MCA PI 8,96,97 the cutoff values

for an abnormal MCA pulsatility index are similar up to about 30 weeks gestational

age but differ after 32 weeks. The normograms we chose to use for analysis are from

the largest published cross-sectional study by Harrington K et al 22.

Positive predictive value of MCA PI 70% in predicting adverse perinatal

outcome is also less than that for other variables, which can be attributed to the more

false positive values.

60

The negative predictive value of 90% is comparable with that Fong et el study.

It is more than the UA PI, thus indicating the usefulness of MCA PI in ruling out the

possibility of adverse perinatal outcome.

Cerebroplacental ratio - It had the highest sensitivity value of 95.6% more

than any other variable. The values were not comparable with any other study because

of variation in the prevalence of IUGR.

The highest sensitivity of cerebroplacental ratio indicates its usefulness of

cerebroplacental ratio in ruling out the possibility of adverse perinatal outcome in

IUGR when the ratio is normal for the gestational age.

It showed the specificity of 85.1% which is less compared to UA PI and better

than the MCA PI. The values were comparable with Fong et al26 study.

Fong K W et al

Gramellini et al Present study

sensitivity 51.3% 68% 95.6%

specificity 80.6% 98.4% 85.1%

PPV 48.1% 94.4% 84.6%

NPV 82.5% 88.8% 95.8%

The positive predictive values 84.6% is less than UA PI and better than MCA

PI. The value was comparable with Gramellini et al12 study.

The negative predictive value 95.8% is better than that of UA PI and MCA

PI. The values were comparable with that of Fong et al K W et al26 and Gramellini et

61

al12 studies. It indicates that the likelihood of prediction of favorable outcome is better

when the cerebroplacental ratio is normal.

Our study agrees with that of Chan et al24 that the cerebroplacental ratio is

more sensitive than UA PI, but at the expense of decreased specificity.

Out of 33.3%(n=8) cases with absent or reversed end diastolic flow in

umbilical artery, 62.5% had perinatal death within one week .100% mortality was

seen in cases with reversed diastolic flow and 50% mortality in cases with absent

diastolic flow. This confirms the findings of Karsdrop etal21, which showed that

absent and reversed diastolic flow is better indicator of the adverse perinatal outcome.

The current study has shown that absent or reversed end – diastolic flow in the

umbilical artery is strongly associated with major perinatal morbidity with mortality.

This has been well recognized in the literature that there is strict correlation between

the abnormal UA PI and poor perinatal outcome in IUGR. Studies have shown that

absent and reversed diastolic flow in the umbilical artery is associated with increased

perinatal mortality and morbidity23, 35, 36, 37.

In our study when we compare the overall diagnostic accuracy in prediction of

adverse outcome in IUGR. Cerebroplacental ratio has the diagnostic accuracy of 90%

which is more than UA PI (86%), MCA PI (78%). The values obtained in our study

are comparable with that of Gramellini et al12.

62

Gramellini et al Present study

MCA/UA PI Ratio 90% 90%

UA PI 83.3% 86%

MCA PI 78.8% 78%

The primary aim of antepartum fetal surveillance is timely recognition of fetal

compromise to enable appropriate intervention and to prevent further serious

complications. If the fetus would otherwise die inutero, delivery might save its life,

but ill-adviced preterm delivery may be followed by postnatal death. Hence Doppler

of fetoplacental circulation plays a significant role in predicting the adverse perinatal

outcome in IUGR fetus which helps in the management of such fetuses.

Our results in evaluating the usefulness of umbilical artery and middle

cerebral artery Doppler in predicting the adverse perinatal outcome in IUGR indicate

that both abnormal umbilical Doppler indices and cerebral-umbilical ratio are strong

predictors of adverse outcome in IUGR. The MCA PI alone is not a reliable indicator

when used alone. The combination of umbilical and fetal cerebral Doppler indices

may increase the utility of Doppler ultrasound in clinically suspected IUGR.

63

Conclusion

CONCLUSION

• Doppler ultrasonography is the best noninvasive investigation to assess changes in

fetal haemodynamics in a clinically suspected IUGR.

• Fetal Doppler indices provide information that is not readily obtained from more

conventional tests of fetal well-being.

• Fetal vessels such as umbilical artery and middle cerebral artery Doppler helps to

differentiate the fetus with pathological growth restriction from that of other small

for gestational age fetuses.

• Both abnormal umbilical Doppler indices and cerebral-umbilical ratio are strong

predictors of adverse outcome in IUGR.

• Umbilical artery Doppler is more useful than middle cerebral artery in prediction

of outcome in IUGR when considered individually.

• Absent and reversed diastolic flow in umbilical artery in IUGR is an ominous

finding, associated with increased mortality and morbidity.

Fetal Doppler study plays a significant role in management of growth

restricted fetus by identifying compromised growth restricted fetus from that of

noncom promised growth restricted fetus.

Fetal Doppler study should be an integral part while evaluating in-utero health

of the growth restricted fetus.

64

Summary

SUMMARY

IUGR is associated with an increased risk of perinatal mortality,

morbidity and impaired neurodevelopment. The correct detection of the compromised

IUGR fetus to allow timely intervention is a main objective of antenatal care.

Doppler ultrasound allows a noninvasive assessment of fetal haemodynamics.

Doppler investigation of the umbilical arteries provides information concerning

perfusion of the fetoplacental circulation, while Doppler study of cerebral vessels

detects the haemodynamic rearrangements that occur in response to fetal hypoxia.

We have studied Umbilical and middle cerebral artery pulsatility index in

about 50 pregnancies with clinical suspicion of IUGR and correlated the findings with

the perinatal outcome. 70% of neonates (n=35) had birth weight of less than 2.5 kg.

There were 7 intra uterine deaths and 43 live births. Of the 42 live births 13 neonates

were admitted to NICU. 6 neonates had 5 min Apgar score of less than 7 and 16

babies was born by emergency caesarian section. Of the 7 IUDs 2 cases had reversal

of diastolic flow and 3 had absent diastolic flow. In all cases with reversal of diastolic

flow, IUD of the fetus occurred with in one week of diagnosis.

In our study MCA PI/UA PI ratio had a higher Sensitivity and negative

predictive value for predicting adverse perinatal outcome when compared to MCA PI

and the UA PI, UA PI had higher specificity and positive predictive value than MCA

PI and MCA PI/ UAPI, MCA PI had the least specificity. The overall diagnostic

accuracy was higher for MCA PI/UA PI than MCA PI and UA PI alone.

65

In our study Cerebroplacental ratio is most sensitive and Umbilical artery PI is

most specific index in predicting adverse outcome.MCA PI is least specific in

predicting adverse perinatal outcome. Absent or reversed end diastolic flow in an

umbilical artery is an ominous finding associated with major adverse perinatal

outcome and mortality.

Thus the umbilical and middle cerebral artery Doppler studies helps in the

prediction of adverse perinatal outcome and management of clinically suspected

suspected IUGR.

66

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Annexure

PROFORMA

Patient Particulars

Name of the Patient: Ref Unit:

Age: Date of Admission:

Address: Date of Discharge:

IP/P Number:

Present Obstetric History

Gestational Age: (whether Dating Based on Early first trimester scan/second

trimester scan/ LMP)

Para: Fetal Movements

Gravida: Maternal Weight Gain:

Living: Any complaints.

Abortions: Warning Signs of Pre Eclampsia

First Trimester:

Second Trimester:

Past Obstetric History:

General Examination: Nutrition Status

Pallor, Icterus, Cyanosis, Edema, Lymphadenopathy.

80

Vitals:

Pulse B.P

Respiratory

Rate

Temperature

P/A Examination: Uterine Fundal Height, FHR,

CVS/RS :

P/V Examination:

Investigations:

Blood Sugar, Hb%, (Serum Uric Acid, HIV, HbsAg , VDRL if done )

Routine Urine analysis (for Albumin, sugar, Micro analysis).

Clinical Diagnosis:

Ultrasound Findings:

Fetal Lie, Position, Number,

Ultra Sound Biometry:

BPD

HC FHR:

AC

FL

Estimated Fetal Weight:

81

Mean Gestational Age:

Liquor:

Placental Maturity:

Any Anomalies:

Doppler Ultrasound Findings:

Value

UA PI .............

(Abnormal if >95th Percentile For Gestation)

MCA PI .............

Abnormal if <5th Percentile for Gestation )

Cerebroplacental Ratio (MCAPI / UA PI) = <1.08 or >1.08 (abnormal if <1.08)

82

KEY TO MASTER CHART

Sl No. - Serial Number

I.P. No. - In Patient Number

GEST - Gestational Age

G - Gravida

P - Para

L - Living

A - Abortions

BOH - Bad Obstetric History

OLIGO - Oligohydramnios

PE - Preeclampsia

IUGR - Intra Uterine Growth Retardation

RHD - Rheumatic Heart Disease

EFW - Estimated fetal weight

UA - Umbilical Artery

UA PI - Umbilical Artery Pulsatility Index

MCA PI - Middle Cerebral Artery Pulsatility Index

EM CS - Emergency Caesarian Section

IUD - Intra Uterine Death

NICU - Neonatal Intensive Care Unit

ADMN - Admission

85

department of radio-diagnosis j.j.m.medical college

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