Doppler Cerebroplacental Ratio Research Articles

Sonographic evaluation of fetal abdominal circumference and cerebroplacental Doppler indices for the prediction of fetal macrosomia in full term pregnant women. Cohort study

Abstract Objectives The aim of the study was to explore the relationship between cerebroplacental Doppler ratio and birth weight in cases of suspected fetal macrosomia. Methods The pulsatility indices of the umbilical (UA-PI) and middle cerebral (MCA-PI) arteries, the cerebroplacental pulsatility index ratio (CPR) and the estimated fetal weight (EFW) were obtained in a cohort of 150 ultrasound-dated pregnancies at ⩾ 37 weeks’ gestation divided into two groups as follows; large for gestational age (LGA, n = 50) and average for gestational age (AGA, n = 100). Results There is a significant difference between groups in abdominal circumference (AC), head circumference (HC), biparital diameter (BPD), estimated fetal weight (EFW) and actual fetal weight with a mean difference of 92.7 g in the LGA group and 84 g in the AGA group. MCA-RI and PI were significantly lower in the LGA group with no difference in UA-RI, PI and CPR-PI between both groups. Conclusions CPR-PI could not differentiate between LGA and AGA.

Combined Sonographic Testing Index and Prediction of Adverse Outcome in Preterm Fetal Growth Restriction

We sought to test the hypothesis that a combined sonographic scoring system (CSTI) that incorporates features of the biophysical profile (BPP) and multivessel Doppler evaluation improves prediction of adverse outcomes in preterm intrauterine growth restriction. This was a prospective cohort study of growth-restricted fetuses with abnormal umbilical artery (UA) Doppler studies, defined as pulsatility index (PI) > 95 th percentile for gestational age or absent/reversed end diastolic flow. Fetuses were followed with weekly BPP and Doppler evaluation of the UA, middle cerebral artery (MCA), and ductus venosus (DV) until the time of delivery. The cerebroplacental Doppler ratio (CPR) was then calculated (MCA PI/UA PI). MCA PI < 5 th percentile, MCA peak systolic velocity (PSV) > 1.5 multiples of the median, DV PI > 95 th percentile with or without absent/reversed flow, and CPR < 1.08 were considered abnormal. Using logistic regression modeling, a weighted scoring index for the prediction of a composite fetal vulnerability index (FVI), which included 5-minute Apgar score < 3, cord pH < 7.2, seizures, necrotizing enterocolitis, grade 4 intraventricular hemorrhage, periventricular leukomalacia, and neonatal death, was developed. A receiver operating characteristic (ROC) curve was used to identify the best score associated with the FVI. Of 66 patients meeting inclusion criteria over a 5-year period, 17 (25.8%) had a positive FVI. Abnormal BPP (< 8), MCA PI, MCA PSV, DV PI, and CPR were observed in 6, 27.3, 13.6, 56.1, and 33.3% of patients, respectively. From the logistic regression model, a CSTI was developed including a score of 1 for abnormal BPP, 3 for MCA PSV, 1 for DV, 6 for CPR, and 3 for oligohydramnios. The ROC curve identified a score of ≥ 7 to be the best predictor of FVI with sensitivity of 35.1% and specificity of 91.8% and a positive likelihood ratio of 4.3 (area under ROC curve 0.73). These test characteristics were better than those for any of the individual component antenatal tests. Although this novel scoring system performs modestly in predicting adverse outcomes in FGR, it appears to perform better than any individual antenatal test currently available.

OC12.06: Aortic and carotid wall thickness in term small‐for‐gestational age newborns with normal and abnormal fetal cerebroplacental Doppler ratio

cardiac function, carotid artery diameter, IMT and stiffness nor in endothelial function. Conclusions: ARED flow seems to contribute to an irreversible restriction of aortic growth persisting into adulthood, while the carotid artery, an adjacent elastic artery, has unchanged geometry and mechanical properties. Even if no altered left ventricular geometry or function were revealed at present, the smaller diameter and higher systolic pressure reflection in the central aorta might have negative consequences for left ventricular performance in the future by increasing aortic impedance.

Metalloprotease (ADAM12-S) as a Predictor of Preeclampsia: Correlation with Severity, Maternal Complications, Fetal Outcome, and Doppler Parameters

Objectives. To compare the first trimesteric serum level of ADAM12-S in women who developed mild and severe preeclampsia and in healthy gravidas and to correlate these changes with the severity of the disease, maternal complications, fetal outcome, and Doppler cerebroplacental ratio (CPR). Design. Comparative prospective observational study. Setting: University hospital. Methods: Serum samples were obtained from 414 women in their first trimester, of which 259 women completed their pregnancy without complications and 155 women developed preeclampsia later in their pregnancies. All were subjected to history taking, examination, laboratory investigations, obstetric ultrasound, and Doppler CPR. Results. ADAM12-S was significantly decreased in patients with severe and in mild preeclampsia compared with the controls. Moreover, there was strong negative correlation with disseminated intravascular coagulopathy (DIC) and HELLP syndrome, cesarean delivery, postpartum hemorrhage, and neonatal intensive care unit admission. ADAM12-S had medium negative correlation with systolic blood pressure and diastolic blood pressure, accidental hemorrhage, cesarean hysterectomy, prematurity, and low birth weight. In addition, it had a weak negative correlation with intracranial hemorrhage, residual hypertension, and intrauterine fetal death. ADAM12-S had strong positive correlation with CPR. There were no correlation with eclampsia, intrauterine growth retardation, acute pulmonary edema, and acute renal failure. Conclusion. ADAM12-S is significantly decreased in severe and mild preeclampsia and is correlated with CPR, severity of preeclampsia, maternal complications, and fetal outcome. It is recommended to measure ADAM12-S in the first trimester to predict maternal complications and fetal outcome in pregnancies complicated by preeclampsia.

The Doppler cerebroplacental ratio predicts non‐reassuring fetal status in intrauterine growth restricted fetuses at term

To investigate whether cerebroplacental ratio (CPR) can be a useful marker to predict non-reassuring fetal status (NRFS) in small for gestational age (SGA) infants at term. Three hundred and nine singleton SGA infants delivered between 37 and 41 weeks of gestation were included in this study. SGA infants were defined as birthweight less than 10th percentile for gestational age. Doppler measurements were recorded once a week until delivery. The incidence of NRFS or an emergency cesarean delivery, and relationship between CPR and NRFS in SGA infants were compared with appropriate for gestational age (AGA) infants at term, and a receiver-operator characteristics curve analysis was performed. The incidences of NRFS was significantly higher in SGA (27.8%) infants compared with in AGA infants (18.0%), and the rate of emergency cesarean delivery was significantly higher in SGA (14.6%) infants compared with AGA infants (8.3%). CPR was obtained from 63 SGA infants, and 16 out of 63 cases (25.4%) resulted in NRFS. The infants complicated with NRFS showed significantly lower CPR values compared with those without NRFS (1.05 ± 0.2 vs 1.23 ± 0.2, P = 0.013), while middle cerebral artery resistance index and 'umbilical artery resistance index were not statistically different between the two groups. A cut-off value of CPR 1.1 based on the receiver-operator characteristics curve provided the best combination with 62.5% sensitivity and 74.5% specificity to predict NRFS occurrence. The SGA infants complicated with NRFS showed significantly lower CPR values compared with those without NRFS.

Doppler Measurement of the Changes of Fetal Umbilical and Middle Cerebral Artery Velocimetric Indices During Continuous Epidural Labor Analgesia

Although complications of the epidural technique are known to affect the fetus adversely, there are no data indicating that regional analgesia directly causes harmful effects to the fetus. Our purpose was to determine the effect of epidural labor analgesia on the Doppler velocimetric indices of the uterine and fetal umbilical and middle cerebral arteries. Doppler velocimetry indices, systolic/diastolic ratios, pulsatility index, and resistance index, of the fetal umbilical artery and uterine artery were recorded in 15 women receiving continuous epidural analgesia with 0.075% bupivacaine and 0.0002% fentanyl during labor; the same indices were recorded of the fetal umbilical and middle cerebral arteries in 10 women receiving the same analgesia. The cerebroplacental Doppler ratio was calculated. Maternal and neonatal outcome data were also recorded. Velocimetric indices of the fetal umbilical and middle cerebral artery after epidural infusion were not significantly different from the pre-epidural infusion levels. Indices of the maternal uterine artery were significantly increased after epidural infusion. The cerebroplacental ratio did not change after the beginning of epidural infusion. Neonatal outcome parameters (1- and 5-min Apgar scores) were all within normal limits. These data suggest that although velocimetric indices of the maternal uterine artery are affected by continuous epidural labor analgesia, fetal circulation, as measured by Doppler velocimetric indices, is not altered.

Elevated Serum-Soluble Fas in Preeclampsia: Correlation with Clinical, Laboratory, and Doppler Parameters

Objectives. (i) To compare the levels of soluble Fas (sFas) in the sera of patients with variable degrees of preeclampsia and in healthy gravidas; and (ii) to correlate sFas with clinical, laboratory, and Doppler parameters in preeclampsia. Methods. Fifty patients with mild preeclampsia, 50 patients with severe preeclampsia, and 50 healthy normotensive pregnant women (control group) were selected from those admitted to the delivery unit. All were nearly of the same maternal and gestational ages. Patients and controls were subjected to (i) history taking; (ii) general, abdominal, and pelvic examination; (iii) laboratory investigations including serum sFas, total bilirubin, aspartate transaminase, alanine transaminase, creatinine, uric acid, hematocrit value, platelet count, and 24 urinary proteins; (iv) obstetric ultrasound and biophysical profile; (v) Doppler cerebroplacental ratio; and (vi) neonatal assessment after delivery. Results. Serum sFas was significantly higher (p < 0.001) in patients with mild and severe preeclampsia than in normal controls, and in patients with severe preeclampsia than in those with mild disease. In preeclampsia group, sFas correlated positively with systolic (r = 0.386; p < 0.001) and diastolic (r = 0.347; p = 0.001) blood pressures, serum uric acid (r = 0.452; p < 0.001), and urinary protein (r = 0.416; p < 0.001); and correlated negatively with biophysical profile (r = −0.371; p < 0.001), cerebroplacental ratio (r = −0.527; p < 0.001), and birth weight (r = −0.458; p < 0.001). Conclusion. Serum sFas is significantly elevated in preeclampsia and is correlated with some important clinical, laboratory, and Doppler parameters. Further longitudinal studies are recommended to investigate the possible value of sFas as an early predictor of preeclampsia and its severity.

Clinical study of cerebrovascular blood flow dynamics in fetus with congenital heart disease

Objective To determine whether CHD modify cerebrovascular flow dynamics in CHD fetuses,and the influence on different types of CHD.Methods Two hundred normal fefuses and 159 fetuses who were diagnosed CHD by prenatal echocardiogram were studied.CHD fetuses were divided into 6 groups according to hemodynamics:hypoplastic left heart syndrome(HLHS,n=23),left-sided obstructive lesions(LSOL,n=19),hypoplastic right heart syndrome(HRHS,n=15),right-sided obstructive lesions (RSOL,n=33),septal defect(SD,n=36),conotruneal defects(CTD,n=33).The pulsatility index(PI) and the cerebroplacental Doppler ratio(CPR)of the middle cerebral artery(MCA)and umbilical artery(UA) in normal and CHD group were measured by color Doppler flow system.Results MCA-PI and CPR in HLHS,HRHS,RSOL,CTD and SD groups all decreased compared with normal fetuses(P 0.05).Conclusions Fetuses with CHD had decreasing eerebrovascular impedance.Different types of CHD had different levels of eerebrovascular impedance,which indicated that different types of CHD induced different levels of cerebrovascular circulationcompensation. Key words: Ultrasonography,prenatal; Heart defects,congenital; Middle cerebral artery; Hemodynamic phenomena

OC29.03: The Doppler cerebroplacental ratio predicts risk of non-reassuring fetal status for fetal growth restriction in term pregnancy

OC29.03: The Doppler cerebroplacental ratio predicts risk of non-reassuring fetal status for fetal growth restriction in term pregnancy

The cerebroplacental Doppler ratio predicts postnatal outcome in fetuses with congenital heart block

Autoimmune-mediated congenital complete heart block (CCHB) is associated with significant perinatal morbidity and mortality, and prenatal monitoring of these fetuses is a significant challenge. The cerebroplacental Doppler ratio (CPR), defined as the ratio of the middle cerebral artery pulsatility index (MCA-PI) to the umbilical artery pulsatility index (UA-PI), is predictive of perinatal outcome in growth-restricted fetuses. This study tests the hypothesis that the CPR would be useful in monitoring fetal well-being in fetuses with CCHB. We reviewed data on all patients diagnosed prenatally with autoimmune-mediated CCHB at our institution over the past 2 years. The fetal echocardiograms from each patient were analyzed for: CPR, UA-PI, MCA-PI, cardiothoracic ratio, degree of tricuspid regurgitation, ventricular function and presence of effusions. We compared hemodynamic data from the fetal echocardiogram before delivery in patients who required urgent pacemaker placement postnatally to those patients that did not require an urgent pacemaker. Five patients with autoimmune-mediated CCHB were identified, and two patients required urgent pacemaker placement. The CPR before delivery was significantly lower in the patients who required urgent pacemaker placement (0.97+/-0.06 versus 1.45+/-0.03; P=0.003), but there was no difference in other fetal echocardiographic markers between groups. Both patients requiring urgent pacemaker placement had a CPR less than 1.08. The CPR is predictive of postnatal outcome in fetuses with CCHB and is useful in prenatal monitoring of these patients.

Nifedipine therapy for preterm labor: effects on placental, fetal cerebral and atrioventricular Doppler parameters in the first 48 hours

To assess the effect of nifedipine tocolysis on Doppler parameters of the uterine, umbilical and fetal middle cerebral arteries and atrioventricular valves in the first 48 h of therapy. Doppler waveforms of uterine, umbilical and middle cerebral arteries and both atrioventricular valves were measured from 28 pregnant women and fetuses prior to and during nifedipine therapy for preterm labor. Maternal and fetal heart rates (FHR), maternal systolic and diastolic blood pressure, and the Doppler pulsatility index (PI) of the uterine, umbilical and middle cerebral arteries were measured. The cerebroplacental ratio (middle cerebral artery PI/umbilical artery PI) was calculated. The total time velocity integrals (TVIs) of tricuspid and mitral valves and their E- and A-wave peak velocity ratio (E/A) were measured. Friedman repeated-measures analysis of variance was used to compare the variables before and after nifedipine therapy. If significant differences were found, Wilcoxon's signed ranks test was used to analyze the difference between the two variables. A P-value of < 0.05 was considered significant. Nifedipine maintenance was associated with a significant decline in maternal systolic and diastolic blood pressure after 24 h, while maternal heart rate and FHR were unaffected. The uterine artery PI had decreased significantly at 24 and 48 h, while the umbilical artery PI did not change significantly. The middle cerebral artery PI had decreased significantly at 24 and again at 48 h. A significant fall in the cerebroplacental Doppler ratio was maintained beyond 24 h. The mean E/A values, TVIs and TVI x FHR values at 24 and 48 h were unchanged from the baseline values. Nifedipine maintenance tocolysis is associated with a significant decline in uterine artery and middle cerebral artery Doppler indices 24 h after the first dose. Fetal cardiac diastolic function is unaffected and the significant redistribution observed after 24 h is likely to be attributable to altered cerebral blood flow.

Cerebroplacental Doppler Ratio and Adverse Perinatal Outcomes in Intrauterine Growth Restriction

The purpose of this study was to compare the impact of using gestational age-specific reference levels of the cerebroplacental Doppler ratio (CPR) with categorical threshold in the prediction of adverse perinatal outcomes in growth-restricted pregnancies. A retrospective cohort study of cases of intrauterine growth restriction over a 3-year period was conducted. The umbilical artery and middle cerebral artery pulsatility indices were converted to CPRs. The efficacy of using gestational age-specific reference levels of CPRs in predicting adverse outcomes was compared with the use of a CPR of less than 1.08. Adverse perinatal outcomes evaluated included cesarean delivery for nonreassuring fetal heart tones, umbilical artery pH less than 7.0, 5-minute Apgar scores less than 7.0, intraventricular hemorrhage greater than grade 2, periventricular leukomalacia, respiratory distress syndrome, and perinatal death. Of 183 pregnancies meeting our inclusion criteria, there were 70 with at least 1 adverse outcome. With the use of a CPR ratio below the 5th percentile for gestational age, the sensitivity, specificity, and positive and negative predictive values for predicting an adverse outcome were 65%, 73%, 73%, and 65%, respectively, with an odds ratio (95% confidence interval) of 5.2 (1.4-19.4; area under the receiver operating characteristic curve, 0.69). With a CPR threshold of less than 1.08, the sensitivity, specificity, and positive and negative predictive values were 72%, 62%, 68%, and 67%, with an odds ratio (95% confidence interval) of 4.2 (1.2-15.3; area under the receiver operating characteristic curve, 0.67). An abnormal CPR is associated with adverse perinatal outcomes in growth-restricted fetuses. The accuracy of using gestational age-specific reference levels was similar to that of using a categorical threshold.

Relationship between cerebroplacental Doppler ratio and birth weight in postdates pregnancies

To explore the relationship between cerebroplacental Doppler impedance index and birth weight in postdates pregnancies, and to evaluate the use of a combination of Doppler parameters and ultrasound biometry in the prediction of large-for-gestational age (LGA) fetuses at 41 weeks of gestation. The pulsatility indices of the umbilical (UA-PI) and middle cerebral (MCA-PI) arteries, the cerebroplacental pulsatility index ratio (CPR) and the estimated fetal weight (EFW) were obtained in a cohort of 181 ultrasound-dated pregnancies at 41 weeks' gestation, 2 days before induction of delivery. A regression equation was established and the correlation between umbilical artery impedance and different birth-weight centile groups was determined. A receiver-operating characteristics (ROC) curve was used to compare prediction of LGA fetuses using biometry alone with that using biometry and UA-PI. UA-PI was inversely related to EFW (Spearson's correlation coefficient rho = -0.28, P < 0.001). Logistic regression showed an independent contribution of UA-PI to the birth-weight estimation (birth weight = 1356.8 - 232.0 x UA-PI + 0.65 x EFW). On ROC curve analysis, the prediction of LGA with the regression equation was comparable to that using ultrasound biometry alone. UA-PI was inversely correlated to EFW, but the combination of ultrasound biometry and UA-PI compared with biometry alone showed similar prediction of LGA fetuses in postdates pregnancies. Further prospective trials on larger populations or groups with a higher prevalence of LGA fetuses would be needed to validate the use of the new formula.

Doppler cerebroplacental ratio for the prediction of adverse perinatal outcome

Doppler velocimetry of umbilical artery is a test of placental function only. Redistribution of cardiac output due to placental abnormality leads to brain sparing effect w1x. It could be detected by abnormal cerebroplacental ratio (CP ratio): the middle cerebral artery resistance index (MCARI)yumbilical artery resistance index (UARI) w2x. Hundred pregnant women with uncomplicated pregnancies between 28 and 40 weeks of gestation and 151 pregnant women at high risk for intrauterine growth restriction (IUGR) and adverse perinatal outcome of same gestational period were included in the study. Doppler velocimetry of UA (from free loops of cord) and MCA (running anteriolateral from the Circle of Willis towards the lateral edge of orbit) was performed weekly or biweekly with the help of 3.5–5 MHz curvilinear transducers along with other tests of fetal well being. The output power was kept at 50 mwycm , high pass filter at 100 2

The cerebroplacental Doppler ratio revisited.

To evaluate the distribution of Doppler pulsatility index (PI) measurements of the umbilical and middle cerebral arteries in singleton fetuses of women with normal uterine artery blood flow and to construct reference ranges for the cerebroplacental PI Doppler ratio. The PI was determined in the mid-portion of the umbilical artery and the mid- or distal segment of the middle cerebral artery in 306 normal singleton fetuses. The cerebroplacental Doppler ratio (CPR) was determined from paired measurements. After determination of the best fit, reference ranges were constructed for each parameter against gestational age (GA). The PI for the umbilical artery had a linear relationship with GA (umbilical artery PI = - 0.0246 x GA + 1.7791, r(2) = 0.4025, P < 0.001). The middle cerebral artery PI and the CPR both showed a quadratic relationship with GA (middle cerebral artery PI = - 0.0058 x GA(2) + 0.3335 x GA - 2.7317, r(2) = 0.2365, P < 0.01), (CPR = - 0.0059 x GA(2) + 0.383 x GA - 4.0636, r(2) = 0.2788, P < 0.001). The CPR is not constant throughout gestation. Reference ranges constructed by a standardized Doppler technique may be of benefit in the monitoring of high-risk pregnancies.

Absent or reversed end-diastolic blood flow in the umbilical artery and abnormal Doppler cerebroplacental ratio--cognitive, neurological and somatic development at 3 to 6 years.

The objective of this study was to examine the cognitive, neurological and somatic developments of children who had in utero an absent or reversed end-diastolic blood flow (ARED) in the umbilical artery or an abnormal cerebroplacental ratio (ABF). 16 children with ARED blood flow and 15 children with ABF were each matched to children with the same gestational age, appropriate for gestational age, the same sex and born within 4 months. Data were assessed at the age of 3-6 years. Children with asphyxia, neonatal infection, malformation or major surgical interventions in the neonatal period were excluded. Each child underwent a neuropediatrical examination; furthermore, a Kaufman Assessment Battery for Children, a Snijders-Oomen Intelligence Scale for Children and a Man-Drawing Test were used to evaluate cognitive development. The socioeconomic status was also assessed. Children in the ARED group remained lighter and had a higher frequency of microcephaly. In the Kaufman Assessment Battery for Children and the Snijders-Oomen Intelligence Scale for Young Children, cognitive development was impaired in the ARED and the ABF groups compared to the control group. The ARED and the ABF groups, however, showed no differences. The Man-Drawing Test and the Denver Development Test did not show any differences. ARED blood flow and ABF showed impaired cognitive development. The degree of impairment was the same in the ARED and the ABF groups. Long-term follow-up studies until adulthood are necessary to see if impaired cognitive development remains significant in these groups of patients.

The Doppler cerebroplacental ratio and perinatal outcome in intrauterine growth restriction

Objective: Our purpose was to determine whether the Doppler cerebroplacental ratio predicts perinatal outcome in fetuses at risk for intrauterine growth restriction. Study Design: The middle cerebral and umbilical artery pulsatility index values were measured in 203 fetuses at risk for intrauterine growth restriction, of which 123 were delivered <3 weeks after the last Doppler examination. Perinatal outcome was categorized as (1) birth weight <10th percentile, (2) birth weight <5th percentile, (3) perinatal complications (meconium-stained fluid, cesarean section for fetal distress, 5-minute Apgar score <7, perinatal death, neonatal intensive care unit stay >24 hours, hypoglycemia, or polycythemia), (4) birth weight <10th percentile plus complications, and (5) birth weight <5th percentile plus complications. The cerebroplacental ratio (middle cerebral artery pulsatility index divided by umbilical artery pul-satility index) values were expressed as multiples of the normal median. Receiver-operator characteristic curves (sensitivity vs false-positive rates) were plotted for the prediction of each category of perinatal outcome and the areas under the curves were determined. Stepwise logistic regression analyses were used to determine whether the cerebroplacental ratio improved outcome prediction over umbilical artery Doppler imaging alone. Results: There was a statistically significant increase in perinatal morbidity and mortality in cases with an abnormal cerebroplacental ratio. The areas under the receiver-operator curves characteristics for the prediction of perinatal outcome with use of the cerebroplacental ratio were statistically very significant. For birth weight <10th percentile we noted P < .001, with P < .0001 for each of the other 4 outcome categories. As shown by regression analyses, the cerebroplacental ratio appeared to improve the prediction of perinatal outcome compared with umbilical artery velocimetry alone. An interesting finding was that the cerebroplacental ratio did not appear to correlate significantly with outcome in fetuses at >34 weeks. Conclusion: Doppler identification of the fetal “brain-sparing” effect strongly predicts outcome in fetuses at risk for intrauterine growth restriction. The brain-sparing effect predicted perinatal problems only in fetuses <34 weeks’ gestation at the Doppler examination. (Am J Obstet Gynecol 1999;180:750-6.)