Normal Doppler Research Articles

INEVITABLE MYOMECTOMY OF EXTRUDING INTRAMURAL FIBROID DURING CAESAREAN SECTION- A CASE REPORT

Myomectomy during caesarean sections have been avoided routinely in the past in the fear of massive hemorrhagewhich may lead to obstetric hysterectomy. However in the recent times with adequate facilities and expertise, caesarean myomectomies are being performed with good outcomes. Case Presentation: A35-year-oldprimi gravida was diagnosed to have intramural fibroid - anterior 4.6*4.3cm and posterior 1.8cm*2.8cm at 8 weeks of gestation.By 13 weeks, during her NT scan there was increase in the size of anterior wall fibroid 7.0*6.6cm, the rest of NT scan and first trimester screening was normal. She developed early onset intrauterine growth restriction in her anomaly scan. She was conservatively managed as the doppler flow was normal. Her scan at 36 weeks showed estimated fetal weight at 2nd centile with normal doppler flow in breech presentation and an anterior intramural fibroid of size 9.5*8.2cm.Hence an elective caesarean section was planned at 37 weeks.Baby was delivered by breech extraction. Manual removal of placenta was done. As the uterus started contracting, the intramural fibroid started extruding, became submucosal and bulging into uterine edges. Hence planned for myomectomy. Injection vasopressin was injected into the surface of myoma,enucleation of the myoma done and myoma bed closed in 2 layers followed by the closure of uterine edges. Intra operative blood loss was around 800ml. No primary or secondary PPH noted. Patient was discharged on 5th post operative day without any complaints. Conclusions: Routine myomectomy at the time of cesarean section is not a standard procedure worldwide. However, it may be considered in carefully selected patients in centers with good facilities to tackle complications by the experienced obstetricians.

Rate of deterioration of umbilical artery Doppler indices in fetuses with severe early-onset fetal growth restriction

ObjectiveTo examine risk factors for the development of absent or reversed end-diastolic velocity (A/REDV) and the time intervals of deterioration from normal UA EDV by S/D, PI or RI to decreased and A/REDV in fetuses with early-onset severe FGR. Study DesignRetrospective cohort study performed from 2005 to 2020. All singleton pregnancies with severe (estimated fetal weight [EFW] or abdominal circumference [AC] below the 3rd percentile) and early-onset (diagnosed between 20 0/7 to 31 6/7 weeks of gestation) were included. Fetal genetic or structural anomalies, suspected congenital infections, A/REDV at diagnosis, poor pregnancy dating and absence of follow-up ultrasounds were excluded. EFW, AC and Doppler indices were reviewed longitudinally from diagnosis to delivery. To examine risk factors for A/REDV, we performed backward stepwise logistic regression and calculated odds ratio with 95% confidence interval (CI). Kaplan-Meier curves were compared using log-rank test. ResultsA total of 985 patients met the inclusion criteria and 79 (8%) progressed to A/REDV. Factors associated with development of A/REDV included gestational age at diagnosis (AOR 4.88 [2.55 – 9.37, 95% CI] at 20 0/7 to 23 6/7 weeks and AOR 1.56 [0.86-2.82, 95%CI] at 24 0/7 to 27 6/7 weeks compared to 28 0/7 to 31 6/7 weeks) and presence of chronic hypertension (CHTN) with AOR 2.37 (1.33 – 4.23, 95% CI). Rates of progression from diagnosis of FGR with normal UA Doppler to A/REDV were significant after 4 weeks from diagnosis (5.84% [4.50 – 7.57, 95% CI]). Regarding the Doppler indices, the progression from normal values to abnormal indices was similar in 1 and 2 weeks however the progression from normal to abnormal S/D ratio compared to PI or RI were higher at 4 and 6 weeks. Deterioration from abnormal indices to A/REDV was shorter with abnormal RI and PI when compared to S/D ratio at 2, 4 and 6 weeks after diagnosis and at 6 weeks, respectively. ConclusionEarlier gestational age at diagnosis and CHTN are considered risk factors for Doppler deterioration and development of A/REDV in the UA. With normal Doppler indices, significant deterioration and progression to A/REDV is unlikely until 4 weeks after diagnosis. Abnormal S/D ratio seems to be appear first. However, abnormal PI or RI was associated with A/REDV.

Comparison Of Maternal And Perinatal Outcome Of Isolated Borderline Amniotic Fluid Index Versus Normal Amniotic Fluid In Low-Risk Pregnancies At Term

Objective: The objective of the study was to compare the maternal and perinatal outcomes in low-risk pregnancies having borderline Amniotic fluid index with normal amniotic fluid index at term. Methods: This prospective observational study, included 540 low-risk pregnant women admitted at POF Hospital Wah Cantt between 1st June 2020-31st Dec 2022. Group A had 180 women with borderline AFI having normal umbilical artery Doppler and group B had 360 women with normal AFI between 37-40 weeks, who fulfilled the inclusion criteria. The data regarding baseline characteristics and fetomaternal outcome was collected on an already designed proforma and analysis was done by using SPSS version 23. Results: The difference in overall cesarean section rate (p=0.071) and cesarean section for fetal distress (p=0.076) was not statistically significant between the two groups. The borderline AFI did not increase the risk of meconium-stained liquor (p=0.116), 5minute APGAR score <7 (p=0.218), admission to NICU (p=0.064) and low birth weight (mean birth weights p=0.278) compared to normal AFI. Conclusion: Borderline oligohydramnios does not increase the risk of cesarean section and cesarean section for fetal distress. There is no increase in the risk of meconium-stained liquor, 5-minute APGAR score<7, admission to NICU and low birth weight. Keywords: Amniotic fluid index, borderline oligohydramnios, cesarean section, fetal distress, meconium-stained liquor.

Poor School Performance As an Indicator of Severity of Sickle Cell Disease

Purpose: Patients with sickle cell anemia can have long term neurocognitive deficits throughout their lifespan. The purpose of this study is to conduct neuropsychiatric evaluations and brain imaging to determine if individuals who have higher risk of falling behind in education can be identified, emphasize the importance of addressing educational needs of these patients, and identify patients who are at risk of developing further complications. Methods: IRB approved retrospective study of patients with Hemoglobin SS disease, who underwent Stanford-Binet Intelligence testing and Woodcock Johnson Achievement. All patients who underwent cognitive testing and also received a transcranial doppler ultrasound or magnetic resonance imaging between were included. All patients were referred to neuropsychiatric testing due to poor school performance. Results: 33 patients were included who underwent neuropsychiatric testing. These students were referred due to poor school performance. Of those, 15 patients had additional imaging studies. All patients were identified with hemoglobin SS disease. All patients were African American. The median age was 9 with an age range of 6 to 16 with a median grade was 4. This sample included 12 females and 3 males. 73% (11 of 15 individuals) were identified with below average full scale intelligence quotient. Of these, 46% (6 of 11) had measurable changes in MRI or transcranial doppler results. 5 of them had measurable changes in transcranial doppler and changes in their MRI, while 1 patient had a normal transcranial doppler, but showed changes in their MRI. On average, the maximum mean velocity was 164 cm/s and was higher than the patients with normal intelligence quotient scores at 148cm/s. The remaining 5 individuals also had below average full scale intelligence quotient without any findings on imaging. All 11 individuals also had below average scores in academic application, academic fluency, and academic skills. On average these patients were 3 years behind on reading, 2 years behind on math, and 2 years behind writing. Only one of these patients had an individualized education plan with extra assistance for education. 7 of the 11 patients with below average full scale intelligence quotients were on hydroxyurea and 2 of the 4 patients with average scores used hydroxyurea. The average hemoglobin level in the group that performed below average was 9.5 and 8.9 in the group that performed average. While, all patients who had average scores on the stanford-binet test did not have any abnormal transcranial dopplers and they all had delays in math, reading, and writing. Conclusion: Below average intelligence and delays in academic performance may be an indicator of patients at risk of developing further complications such as stroke.The full extent to this relationship is unclear. Further research is needed to determine the relationship between intelligence, academic performance and changes in imaging. Earlier detection of these patients can prevent further complications, develop individual treatment plans, and target closer monitoring. A multidisciplinary approach to treating patients with sickle cell disease should include neuropsychiatric evaluations, an assessment of academic achievement, and the opportunity for additional support in school to fully address the needs of this population.

Postnatal genetic and neurodevelopmental assessment in infants born at term with severely low birth weight of non-placental origin.

To determine the frequency of genetic syndromes and childhood neurodevelopmental impairment in non-malformed infants born at term with severely low birth weight and no evidence of placental insufficiency. This case series was constructed from the data of infants delivered at term between 2013 and 2018 with severely low birth weight, defined as birth weight more than 2.5 SD below the mean, with normal maternal and fetal Doppler (umbilical artery, fetal middle cerebral artery, cerebroplacental ratio and uterine artery) and no maternal hypertensive disorder during pregnancy or fetal structural anomaly on prenatal ultrasound examination. Clinical exome sequencing and copy number variation (CNV) analysis were performed using DNA extracted from the children's saliva. Cognitive and psychomotor development was evaluated using the Bayley Scales of Infant and Toddler Development, 3rd edition or the Wechsler Intelligence Scale for Children, 5th edition tests, according to the child's age at testing. Among the 36 405 infants born within the study period, 274 (0.75%) had a birth weight below -2.5 SD, of whom 98 met the inclusion criteria. Among the 63 families contacted, seven (11%) reported a postnatal diagnosis of a genetic syndrome and a further 18 consented to participate in the study. Median gestational age at delivery was 38.0 (interquartile range (IQR), 37.3-38.5) weeks and median birth weight was 2020 (IQR, 1908-2248)g. All 18 children showed a normal result on clinical exome sequencing and CNV analysis, but six (33%) obtained a low score on neurodevelopmental testing. Non-malformed severely small term infants with no clinical or Doppler signs of placental insufficiency present a high rate of genetic syndromes and neurodevelopmental impairment during childhood. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Renal artery aneurism and renal autotransplantation: review of surgical technique, preoperative complementary examinations and postoperative follow-up protocol

Introduction: Renal artery aneurysm (RAA) is a rare pathology; however, its incidental diagnosis is increasingly frequent due to the increasing use of imaging techniques. Complex (hilar) RAAs, dependent on the distal renal artery and its branches, constitute a subset of RAAs that present a therapeutic challenge due to their anatomical location and may require extracorporeal arterial repair and autotransplantation. Material and methods: A bibliographic review is carried out to homogenize the management of this pathology, analyzing the indications for surgical treatment, the recommended surgical technique step by step, as well as post-surgical monitoring. Two clinical cases of RAA treated in our center by hand-assisted laparoscopic nephrectomy, ex vivo bench repair and renal autotransplantation are presented. Results: In both cases, a postoperative Doppler ultrasound of the graft was performed 24 hours later, in which a renal graft was observed in the iliac fossa, of normal size and cortical thickness within normality with normal color Doppler signal, and spectral curves without alterations. Both patients presented oligoanuric acute renal failure (injury) during the immediate postoperative period (first 24 hours) with complete resolution at discharge, which occurred on the 11th and 12th postoperative day, respectively. In both patients a diuretic renogram with MAG3 was performed. In case 1, it was performed the third postoperative month and a slightly ectatic right kidney was observed with less perfusion and parenchymal incorporation of the radiotracer, with a reduction in relative renal function (39.47%) and MAG3 clearance (indeterminate renographic pattern). In this patient, a CT scan with the excretory phase was performed simultaneously, in which a grafted right kidney was seen at the level of the right iliac fossa with good contrast elimination in the excretory phase bilaterally and symmetrically. A small non-perfused area is observed in the upper pole. In the second patient, the renogram was performed on the 14th postoperative day, finding the morphofunctional study of the graft within normal parameters without detecting areas of hypoperfusion. The levels of creatinine and glomerular filtration were, respectively, in the first case: 0.86mg/dl and 90.19ml/min/1.73m2 preoperatively and 0.83mg/dl and 90.96ml/min/ 1.73m2 per postoperative month. In the second case, the values were: preoperatively creatinine of 0.66mg/dl and glomerular filtration rate of 97.96ml/min/1.73m2 and 0.81mg/dl and 89ml/min/1.73m2 one month postoperatively. Conclusion: After reviewing the literature, there is no consensus regarding the imaging techniques to be performed after renal autotransplantation and the optimal time frames for performing these for the evaluation of the postoperative graft. There is also no homogeneity in the imaging techniques to be performed in the preoperative assessment. In our experience, open ex vivo surgical repair of complex distal hilar RAAs has been successful with low morbidity and mortality and an acceptable rate of preservation of renal function.

Mid-trimester uterine artery Doppler for aspirin discontinuation in pregnancies at high risk for preterm pre-eclampsia: Post-hoc analysis of StopPRE trial.

To assess whether aspirin treatment can be discontinued in pregnancies with normal uterine artery pulsatility index (≤90th percentile) at 24-28 weeks. Post-hoc analysis of a clinical trial. Nine maternity hospitals in Spain. Pregnant individuals at high risk of pre-eclampsia at 11-13 weeks and normal uterine artery Doppler at 24-28 weeks. All participants received treatment with daily aspirin at a dose of 150 mg. Participants were randomly assigned, in a 1:1 ratio, either to continue aspirin treatment until 36 weeks (control group) or to discontinue aspirin treatment (intervention group), between September 2019 and September 2021. In this secondary analysis, women with a UtAPI >90th percentile at 24-28 weeks were excluded. The non-inferiority margin was set at a difference of 1.9% for the incidence of preterm pre-eclampsia. Incidence of preterm pre-eclampsia. Of the 1611 eligible women, 139 were excluded for UtAPI >90th percentile or if UtAPI was not available. Finally, 804 were included in this post-hoc analysis. Preterm pre-eclampsia occurred in three of 409 (0.7%) women in the aspirin discontinuation group and five of 395 (1.3%) women in the continuation group (-0.53; 95% CI -1.91 to 0.85), indicating non-inferiority of aspirin discontinuation. Discontinuing aspirin treatment at 24-28 weeks in women with a UtAPI ≤90th percentile was non-inferior to continuing aspirin treatment until 36 weeks for preventing preterm pre-eclampsia.

Quantification of Doppler Indices, Contrast Ultrasound Enhancement Phases and Perfusion Parameters of Hepatic Parenchyma in Healthy Dogs

Background: The Liver is a well vascularized organ. Any pathology can impede its blood flow and this makes liver the most suitable organ for studying the Doppler indices and contrast enhanced perfusion parameters. Methods: This clinical study enrolled 9 healthy dogs including 2 breeds each of beagle, German shepherd, Labrador Retriever, and one breed each of Crossbred, Pug and Pit bull. Spectral Doppler sonography and contrast enhanced ultrasonography (CEUS) of liver vasculature using a second generation contrast agent (Sonovue) was performed to standardize their normal pulsed-wave Doppler indices and contrast enhanced perfusion parameters. Result: The mean ± SE values of Doppler indices of portal vein were PSV (27.68 ± 2.08 cm/s), EDV (15.32 ± 1.74 cm/s), MV (14.05 ± 1.94 cm/s), RI (0.44 ± 0.05) and PI (0.93 ± 0.11). Mean ± SE value of Doppler indices of hepatic artery were 53.78 ± 3.45 cm/s (PSV), 13.90 ± 1.82 cm/s (EDV), 21.63 ± 1.21 cm/s (MV), 0.73 ± 0.04 (RI), 1.93 ± 0.28 (PI) and for hepatic vein were 38.62 ± 4.62 cm/s (PSV), 11.92 ± 2.79 cm/s (EDV), 17.72 ± 2.95 cm/s (MV), 0.69 ± 0.06 (RI), 1.69 ± 0.23 (PI). CEUS of hepatic parenchyma showed three phases viz arterial, portal and late portal phase. Mean ± SE values of contrast enhanced hepatic perfusion parameters (in seconds) were 7.22 ±0.40 (Arrival time), 16.33 ±1.38 (Time to initial peak), 30.22 ±1.29 (Time to final peak), 54.55 ±2.93 (Decline time) and 160.78±8.60 (Washout time).

Corpus callosum-fastigium and tectal lengths in late-onset small fetuses.

To investigate measurements on neurosonography of midbrain morphology, including corpus callosum-fastigium length and tectal length, in late-onset small fetuses subclassified as small-for-gestational-age (SGA) or growth-restricted (FGR). This was a case-control study of consecutive singleton pregnancies delivered at term at a single center between January 2019 and July 2021, including those with late-onset smallness (estimated fetal weight (EFW) < 10th centile) and appropriate-for-gestational-age controls matched by age at neurosonography. Small fetuses were further subdivided into SGA (EFW between 3rd and 9th centile and normal fetoplacental Doppler) and FGR (EFW < 3rd centile or EFW < 10th centile with abnormal cerebroplacental ratio and/or uterine artery Doppler). Transvaginal neurosonography was performed at a mean ± SD gestational age of 33 ± 1 weeks in all fetuses to evaluate corpus callosum-fastigium length and tectal length in the midsagittal plane. Intra- and interobserver agreement was evaluated using the intraclass correlation coefficient and Bland-Altman plots. A total of 70 fetuses with late-onset smallness (29 with SGA and 41 with FGR) and 70 controls were included. Compared with controls, small fetuses showed significantly shorter corpus callosum-fastigium length (median (interquartile range), 44.7 (43.3-46.8) mm vs 43.7 (42.4-45.5) mm, P < 0.001) and tectal length (mean ± SD, 10.5 ± 0.9 vs 9.6 ± 1.0 mm, P < 0.001). These changes were more prominent in FGR fetuses, with a linear trend across groups according to severity of smallness. Corpus callosum-fastigium length and tectal length measurements showed excellent intra- and interobserver reliability. Small fetuses exhibited shorter corpus callosum-fastigium length and tectal length compared with controls, and these differences were more pronounced in fetuses with more severe smallness. These findings illustrate the potential value of midbrain measurements assessed on neurosonography as biomarkers for brain development in a high-risk population. However, further studies correlating these parameters with postnatal functional tests and follow-up are needed. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Second trimester abnormal uterine artery Dopplers and adverse obstetric and neonatal outcomes when PAPP-a is normal

Objectives To explore the association between abnormal uterine artery Dopplers (combined PI > 2.5) - with normal PAPP-A - and adverse obstetric/neonatal outcomes. Methods This was a retrospective cohort study of 800 patients between 1 March 2019 − 23 November 2021 in a tertiary UK hospital, where it is routine to measure uterine artery Dopplers of all pregnancies during their anomaly scans. 400 nulliparous women/birthing people with complete data were included. 400 nulliparous controls scanned in the same time frame (1.5 years) with normal PAPP-A and uterine artery Dopplers were matched for age and BMI. Outcomes included: mode of birth, postpartum complications, birth weight/centile, Apgar score, gestational age at delivery, neonatal unit admission, and clinical neonatal hypoglycemia. Multivariable analysis was used. Results Compared to controls, pregnancies with abnormal uterine artery Dopplers and normal PAPP-A were at increased risk of induction (46.5% vs 35.5%, p = .042), cesarean section (46.0% vs 38.0%, p = .002), emergency cesarean section (35.0% vs 26.5%, p = .009), and pre-eclampsia 5.8% vs 2.5%, p = .021). Their babies were more likely to be admitted to the neonatal unit – mostly for prematurity (15.3% vs 6.3%, p = .0004), hypoglycemia (4.0% vs 1.0%, p = .007), be small for gestational age (26.5% vs 11.5%, p = .0001), had intrauterine growth restriction (10.8% vs 1.3%, p = .0001), and be born prematurely (10.0% vs 3.5%, p = .002). Routine measurement of uterine artery Dopplers increased the detection rate of small for gestational age fetuses by 15.1%. Over half of the babies admitted with neonatal hypoglycemia in pregnancies with abnormal uterine artery Dopplers had an unexplained cause. Conclusions Pregnancies with abnormal uterine Dopplers are not only at increased risk of pre-eclampsia and small for gestational age fetuses/intrauterine growth restriction, but are also at increased risk of emergency cesarean section and adverse neonatal outcomes. The increased incidence of neonatal hypoglycemia is likely driven to some degree by prematurity and placental complications, but possibly also by undiagnosed glucose dysmetabolism. This may warrant routine measurement of uterine artery Dopplers in all pregnancies (regardless of risk), where feasible, to aid antenatal management and counseling.

Normal umbilical artery doppler values in 18–22 week old fetuses with single umbilical artery

Umbilical cord with a single umbilical artery (SUA) can carry twice the blood volume of a three-vessel cord (TVC). So, the normal hemodynamics of the fetuses with SUA was different from those with TVC. Furthermore, structural abnormalities, fetal aneuploidy, and intrinsic growth retardation may be associated with the presence of a SUA. In order to evaluate these patients, intermittent doppler measurements have been suggested. From this point, we aimed to determine the CDUS flow parameters in SUA cases and to demonstrate that these flow parameters are different from the TVC parameters. Ultrasound (US) examinations were performed in the 18–22 weeks of gestation during routine fetal anatomy screening. Resistance index (RI), Pulsatility index (PI), and S/D: systole to diastole ratio values were measured. The samples were taken from the proximal, mid-portion, and distal of the umbilical cord. In addition to Doppler Ultrasound values, AC and estimated fetal weight (EFW) values were also recorded. The study included 167 pregnant women, 86 of whom were study group with SUA and 81 were control group with TVC. The measurements of RI, PI, and S/D at all three levels were significantly lower in the SUA group compared to the TVC group. The resistance in the UA of fetuses with SUA is lower than in fetuses with TVC. The resistance in the UA of fetuses with SUA decreases from the fetal end to the placental end. Knowing the normal values for fetuses with SUA might provide a better and more reliable Doppler Ultrasoundassessment.

Impact on postoperative, neonatal and 2-year neurodevelopmental outcomes of UA-AREDF during and after fetal spina bifida repair.

Absent or reversed end-diastolic flow (AREDF) in the umbilical artery (UA) on Doppler is a known phenomenon during fetal interventions, such as fetal open spina bifida (OSB) repair. We aimed to evaluate the clinical importance of these Doppler findings by investigating the impact of UA-AREDF on postoperative, neonatal and 2-year neurodevelopmental outcomes. This was a prospective study of pregnancies undergoing fetal OSB repair at the Zurich Center for Fetal Diagnosis and Therapy between 2010 and 2019. The group with UA-AREDF during or immediately after the intervention was compared to the group with normal UA Doppler. Primary endpoint was the FIGO scores of cardiotocography (CTG) 1, 2 and 6 h postoperatively and on day 1 after surgery. Secondary endpoints were the neonatal parameters and 2-year neurodevelopmental outcome assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. Data of 130 patients were analyzed. None of the fetuses had UA-AREDF before OSB repair. Normal UA Doppler was observed in 107 (82%) patients and UA-AREDF was observed in 23 (18%) during or immediately after OSB surgery. UA-AREDF was more often observed after version of the fetus (P = 0.045). Seventeen (13%) cases had absent end-diastolic flow (UA-AEDF) and six (5%) cases had reversed end-diastolic flow (UA-REDF). UA-AREDF disappeared in all 23 cases within the first day after OSB surgery. One-third of all CTGs were restricted in oscillation after surgery, but no significant difference in CTG 1, 2 and 6 h postoperatively or on the first postoperative day was found between the UA-AREDF and normal-Doppler groups (P > 0.05). Gestational age at delivery, UA pH, 5-min Apgar score and birth weight were comparable between the two groups, and there was no difference in the 2-year neurodevelopmental outcome (P > 0.05). The neonatal and 2-year neurodevelopmental outcomes also did not differ significantly between the UA-REDF and UA-AEDF groups. Postoperative CTG abnormalities occur and recover at a similar rate in fetuses with transitory UA-AREDF and those with normal Doppler during fetal OSB repair. UA-AREDF during fetal OSB repair did not negatively influence postnatal or 2-year neurodevelopmental outcomes. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Variation of Normal Portal Venous Doppler Indices in Post-Operative Period Following Living Donor Liver Transplant

Objective: To investigate the variations in normal Doppler indices of the portal vein during the post-operative period following living donor liver transplantation (LDLT). Methodology: This retrospective cohort study was carried out at Pakistan Kidney and Liver Institute and Research Centre from July 1 to December 31 2021. It included all adult patients over 16 years of age who underwent Living Donor Liver Transplant (LDLT). Triplex Doppler ultrasound of LDLT recipients was performed intraoperatively and postoperatively for 5 consecutive days. Subsequent scans were performed at 2 weeks, 4 months, and 6 months after the transplant. Portal vein velocities were taken at the extrahepatic part, anastomosis, and intrahepatic part. Statistical analysis was performed using SPSS version 20. Results: The study involved 91 patients, with ages ranging from 17 to 73 years and a mean age of 44.9 years. Among the recipients, 79% were male and 21% were female. The portal venous velocities varied between 31 cm/s and 357 cm/s. All patients had antegrade portal venous flow. The portal venous velocities normalized within 4-6 months following LDLT. Conclusion: A wide range of portal venous velocities can be encountered following LDLT without clinically significant outcome and these usually normalize within 4-6 months following LDLT.

Placental pathology in pregnancies with late fetal growth restriction and abnormal cerebroplacental ratio

IntroductionLate fetal growth restriction (FGR) is associated with mild growth restriction and normal or mild abnormal doppler flows. The cerebroplacental ratio (CPR) has been demonstrated as more sensitive to hypoxia than its individual components in these fetuses. We hypothesized that abnormal CPR in late FGR is reflected in specific placental vascular malperfusion lesions. MethodsRetrospective cohort study of late FGR newborns between 2012 and 2022 in a tertiary hospital. Overall, 361 cases were included: 104 with pathological CPR (study group), and 257 with normal doppler flows (control group). The primary outcome was a composite of maternal vascular malperfusion lesions (MVM) and fetal vascular malperfusion lesions (FVM). Secondary outcomes were macroscopic placental characteristics and various obstetrical and neonatal outcomes. ResultsThe study group had lower birthweight compared with the normal CPR group (2063.5 ± 470.5 vs. 2351.6 ± 387.4 g. P < 0.0001), higher rates of composite adverse neonatal outcomes (34.2% vs. 22.5%, p < 0.0001), lower mean placental weight (318 ± 71.6 vs. 356.6 ± 76.5 g, p < 0.0001), as well as a higher prevalence of Vascular lesions of MVM (15.3% vs. 5.0%, p = 0.002), villous lesions of FVM (37.5% vs. 24.9%, p = 0.02), and composite FVM lesions (36.5% vs. 25.6%, p = 0.04). On multivariate regression analysis for MVM lesions and composite FVM lesions, abnormal CPR was found as an independent risk factor (aOR 2.17, 95% CI 1.63–4.19, and aOR 1.31, 95% CI 1.09–3.97, respectively). DiscussionsAbnormal CPR in late FGR is reflected in placental histopathologic vascular malperfusion lesions, and the incidence of these lesions is higher than in FGR placentas with normal CPR.

Analyses of the soluble levels of sCD40L, sCD62P and sCD40 in pediatric sickle cell anemia patients with abnormal transcranial Doppler

IntroductionSerum levels of sCD40L, sCD40 and sCD62P were evaluated in sickle cell anemia (SCA) patients aged between 2 and 16 years with normal transcranial Doppler (TCD) and no stroke (G1, n = 24); in SCA patients with abnormal TCD (G2, n = 16); in SCA patients with a previous history of stroke (G3, n = 8), and; in healthy controls (aged 2 to 13 years; n = 26). ResultsThe levels of sCD40L were significantly higher in the G1, G2 and G3 groups, compared to controls (p = 0.0001, p < 0.0002 and p = 0.004, respectively). Among patients with SCA, higher levels of sCD40L were found in the G3 group, compared to the G2 group (p = 0.03). In the sCD62P analysis, high levels in G3, compared to G1 (p = 0.0001), G2 (p = 0.03) and G4 (p = 0.01), and G2 also had high levels, compared to G1 (p = 0.04). The G1 patients had a higher sCD40L/sCD62P ratio, compared to G2 (p = 0.003) and controls (p < 0.0001). The sCD40L/sCD40 ratios were higher in G1, G2 and G3, compared to controls (p < 0.0001, p = 0.008 and p = 0.002, respectively). ConclusionIt was concluded that the combination of TCD abnormality, associated with levels of sCD40L and sCD62P, may contribute to a better assessment of the risk for stroke in pediatric SCA patients.Favor pedir para os autores corrigirem esta frase, pois NÃO é uma sentença completa em inglês: Our data suggest that decreased values of the s[LSM1] CD40L/sCD62P ratio involving two inflammatory mediators produced in platelet activation, being unprecedented in the literature.

Comparison of modified biophysical profile and doppler ultrasonography studies in predicting perinatal outcome in high-risk pregnancies

In order to improve perinatal outcomes and reduce mother and foetal morbidity and mortality especially in high-risk pregnancies, there is an immense need to do thorough antepartum surveillance test. Aims and Objectives: To compare modified biophysical profile (MBPP) and Doppler studies results for prediction of perinatal outcome and to evaluate the association between the mode of delivery and abnormal Doppler and MBPP.Methodology: This is a prospective observational and comparative study. High-risk term patients were taken in this study, following which MBPP and Doppler studies were performed within 48 to 72 hours of delivery.The study population were divided as follows and perinatal outcome was assessed:A-Normal MBPP and normal Doppler velocimetryB-Normal MBPP and abnormal Doppler velocimetryC-Abnormal MBPP and normal Doppler velocimetryD-Abnormal MBPP and abnormal Doppler velocimetry.Results: The high-risk factor for the greatest number of patients, which accounted for 39.33% of patients, was pregnancy-induced hypertension. Age was less than 25 years in 88 patients (55%). 67 patients were primigravida (44.7%), LSCS was the mode of termination of pregnancy in 127 (84.7%) patients.Greatest prenatal complications occurred in individuals who had abnormal MBPP and Doppler, with a significant P value of < 0.05., Subsequently followed by MBPP, which had a significantly higher NPV than Doppler studies (63.64% vs. 59.41%), which makes it helpful for identifying healthy new-borns.Conclusion: In our study, it was determined that better prediction of adverse perinatal outcome was observed when both Doppler studies and MBPP was done in combination followed by MBPP.

Late-Onset Severe Fetal Growth Restriction and Isolated Severely Small Abdominal Circumference: Do Neonatal Outcomes Differ? [ID: 1377666

INTRODUCTION: Updated guidelines from the Society for Maternal-Fetal Medicine (SMFM) define severe fetal growth restriction (sFGR), or an estimated fetal weight (EFW) less than 3rd percentile, as a distinct entity due to higher perinatal morbidity in this group. Whether an isolated abdominal circumference (AC) less than 3rd percentile similarly portends adverse outcomes remains unclear. METHODS: This is a single-institution, retrospective cohort study of singleton gestations with late-onset FGR and normal Doppler studies from 2012 to 2022. Pregnancies affected by AC less than 3rd percentile (but EFW≥3rd percentile) and EFW less than 3rd percentile were compared using univariable analysis and multivariable logistic regression. The primary outcome was neonatal intensive care unit (NICU) admission. RESULTS: Among eligible participants, 78 (63%) had an isolated AC less than 3rd percentile and 45 (37%) had sFGR. Neonates prenatally diagnosed with sFGR were more likely to be admitted to the NICU than those with isolated AC less than 3rd percentile (68.9% versus 23.1%, P&lt;.001). After adjusting for gestational age, birth weight, race, maternal age, and medical comorbidities, sFGR was still associated with an increased odds of NICU admission (adjusted odds ratio 4.9, 95% CI 1.37–17.48, P=.014). Rates of cesarean delivery (46.7% versus 26.9%; P=.03), small for gestational age (86.7% versus 67.9%, P=.02), and 5-minute Apgar score less than 7 (6.7% versus 0.0%, P=.02) were also higher in the sFGR group. There were no significant differences in NICU length of stay or perinatal death between groups. CONCLUSION: Adverse neonatal outcomes were more prevalent in pregnancies affected by sFGR compared with isolated AC less than 3rd percentile, providing support for the updated SMFM guidelines.

Diastolic deceleration area in the fetal MCA: a new Doppler parameter

Objective Doppler velocimetry has been widely used throughout the years as a valuable tool in the follow-up and prognosis of various pregnancy complications. Numerous Doppler indices have been introduced to qualitatively describe fetal blood flow. Currently, the Pulsatility index (PI) is the most widely used index for this purpose. In current clinical practice, middle cerebral artery (MCA) PI measurement is commonly used to assess fetal well-being, especially in late-onset fetal growth restriction (FGR). However, existing evidence suggests that MCA PI alone is inferior to the ratio between MCA and umbilical artery (UA) pulsatility indices in predicting adverse perinatal and neonatal outcomes. When comparing normal and abnormal MCA Doppler waveforms, it is evident that most changes appear in the diastolic part of the heart cycle. Therefore, the PI, which contains elements from both systole (peak systolic velocity–PSV) and diastole (end-diastolic velocity), may not be the most effective tool for quantifying fetal brain sparing (BS). Methods We hypothesize that another measurement modality that focuses predominantly on the diastole could be more efficient for evaluating the amount of vasodilatation. In ultrasound velocimetry of larger blood vessels, there is a well-known phenomenon called “dicrotic notch” (DN), which appears on the declining part of each Doppler waveform and can be used to precisely pinpoint the end of systole and the start of diastole. We hypothesized that the extent of cerebral vasodilation can be more accurately assessed by measuring the area between the dicrotic notch (DN) and the end-diastolic velocity (which we refer to as the “diastolic deceleration area–DDA”). In this study, we introduced a new Doppler parameter along with a rationale for DDA measurement in the fetal MCA. We also defined third-trimester nomograms and provided a preliminary assessment of the correlation between DDA and fetal oxygen deficiency. Results Our findings suggest that the DDA may serve as an independent instrument for identifying hypoxia during late pregnancy, either on its own or in conjunction with other Doppler and cardiotocography modalities. Conclusion However, before incorporating DDA into clinical practice, it is crucial to conduct further research and validation studies with larger sample sizes and more diverse populations. This would help assess the generalizability of the results and establish optimal cutoff points for DDA in various clinical settings. It is also important to prospectively study the role of DDA in early- and late-onset fetal growth restriction (FGR), Rh-isoimmunization/anemia, preeclampsia, gestational diabetes, and other pregnancy complications. In fact, we believe that the concept of measuring specific areas in arterial Doppler velocimetry indices could have significant implications not only in fetal medicine and obstetrics, but also in other areas of human and veterinary medicine.

The role of umbilical artery Doppler analysis in estimating perinatal morbidity and mortality in hypertensive pregnancy

Aims: Uteroplacental (uterine artery systolic/diastolic (S/D) ratio) and fetal circulation changes (umbilical artery pulsatility Index (PI) value) can be evaluated non-invasively by using Doppler ultrasonography spectral analysis. The present study aimed to demonstrate how Doppler ultrasonography should be combined with classical well-being tests to detect perinatal morbidity and mortality in hypertensive pregnancy. Methods: This prospective research was carried out with 88 pregnant women diagnosed with high-risk pregnancy and hypertension between April 1992 and May 1994. A non-stress test (NST) was performed in all cases, and fetal distress was evaluated by a biophysical profile (BP) and/or a contraction stress test (CST) subsequent to a non-reactive NST. Following the diagnosis of hypertension, longitudinal maternal (uterine artery) and fetal (umbilical artery) Doppler analyses were initiated at 7–10-day intervals. In the study, the Acuson 128 XP 10 device (Research project No. 515/080555592 was funded by the İstanbul University Research Fund) and a 3.5-5 MHz curvilinear probe were used. No Doppler pathology was considered solely in the timing of delivery. Results: There was no case of perinatal loss, antepartum and intrapartum fetal distress, neonatal asphyxia, and oligohydramnios in the group with normal uterine and umbilical artery Doppler analyses. There was one case with umbilical artery Doppler flow pathology only, which was delivered by preterm cesarean section with the diagnosis of antepartum fetal distress. Fetus diagnosed to have a fetal growth restriction (FGR) and the findings of fetal distress, FGR, and cesarean delivery were concordant with the literature. There was also increased perinatal mortality (9.1%) among patients with pathological uterine artery Doppler and normal umbilical artery Doppler group, but there was no case of oligohydramnios in this group and the rate of neonatal asphyxia (5.min Apgar score &lt;7) was 21.7%. The antepartum loss was 27%, the neonatal loss was 23.8%, and perinatal mortality was 44.8% in the group with pathological uterine and umbilical artery Doppler findings, and this group had all cases of oligohydramnios. Conclusion: Overall, it seems reasonable to identify any pathologies with Doppler ultrasonography in hypertensive pregnant women in the early pregnancy and to follow them up with classical fetal antepartum surveillance tests at appropriate intervals related to their umbilical artery Doppler pathologies.

The Association of Abnormal Doppler and Abnormal Amniotic Fluid Volume in the Third Trimester of Pregnancy with Preterm Birth in Pregnant Women in Agra, India.

Aim This article determines the association and diagnostic effectiveness of abnormal Doppler and abnormal amniotic fluid volume (AFV) in the third trimester of pregnancy with preterm births. Methods The third trimester screening protocol of the Samrakshan program of the Indian Radiological and Imaging Association utilizes trimester-specific fetal Doppler studies and ultrasound assessments, estimation of the risk for preterm preeclampsia (PE), assessment of the fetal environment, growth, and structure, and staging of fetal growth restriction. A multivariate logistic regression model was used to explore associations of abnormal Doppler and AFV with preterm birth. The diagnostic effectiveness of Doppler and amniotic fluid measurements for preterm births was assessed. Results One hundred and sixty-one (25.6%) of the 630 women had a preterm birth before 37 gestational weeks. Eighty (21.1%) of the 379 women with normal AFV and normal fetal Doppler studies in the third trimester had a preterm birth. The proportion of preterm birth declined from 35.14% in 2019 to 19.53% in 2022 (chi-square test p = 0.009). Preterm birth was associated with preterm PE (adjusted odds ratio: 3.66, 95% confidence interval: 1.42, 9.44) in a multivariate logistic regression model. Both abnormal fetal Doppler and AFV did not have a good discriminatory ability for preterm births. Conclusion Integration of fetal Doppler studies helped reduce the preterm birth rate by providing an objective measure of fetal well-being, contrary to a common belief that the use of color Doppler in the third trimester may result in iatrogenic increased preterm birth. Preterm births are associated with preterm PE and early identification of high-risk women and early initiation of low-dose aspirin may have an added benefit on preterm birth rates.