Reverse End-diastolic Flow Velocities Research Articles

Prognostic factors of perinatal short-term outcome in severe placental insufficiency using Doppler sonography to assess end-diastolic absent and reverse blood flow in umbilical arteries

Significant placental insufficiency, indicated by Doppler ultrasound findings of absent or reverse end-diastolic flow velocities (AREDV), is associated with increased morbidity and mortality. Analysis of blood flow in the ductus venosus should assist in early intrauterine recognition of threatened foetuses. 58 high-risk pregnancies with umbilical AREDV were repeatedly examined (n=364). Doppler findings were correlated with neonatal signs of deterioration (ratio of normoblasts to leukocytes, pH, base excess, Apgar score), as well as short-term morbidity [need for intubation, duration of assisted respiration, evidence of respiratory distress syndrome (RDS), bronchopulmonary dysplasia (BPD), necrotising enterocolitis (NEC), intraventricular haemorrhage (IVH grade III+IV)] against the analysis of the blood flow findings (normal or increased pulsitility, absence or reverse end-diastolic flow) in the umbilical arteries (AU), the middle cerebral arteries (ACM) and ductus venosus (DV) relating these to birth weight and the duration of the pregnancy. The median period of observation was 12.8 days, 48% of the foetuses showed an abnormal ductus venosus flow and 26% an absent venous or reverse end-diastolic flow. The median date of delivery was 30 weeks, with a mean birth weight of 816 g. 93% were live births with 12% dying postnatally. Although the criteria for postnatal morbidity (BPD, NEC, IVH III+IV) and mortality did not correlate with changes in arterial and venous Doppler parameters in our group, there was a significant relationship between the normoblast count, known to be a marker of chronic hypoxia. The Apgar 10 minte score, umbilical arterial pH and base excess were correlated with changes in the DV flow curves. Healthy survival started, irrespective of arterial or venous blood flow criteria, from 27+0 weeks of pregnancy. If born between 27.0 and 30+6 weeks, the infants were more likely to be healthy the less the blood flow had been compromised. A birth weight of 590 g (sensitivity 62.5%; specificity 93.5%) and gestational age of 28+5 weeks (sensitivity 87.5%; specificity 90.3%) were shown to be cut-off points between healthy survival and survival with serious neonatal complications.

Three-dimensional HDlive rendering images of the TRAP sequence in the first trimester: reverse end-diastolic umbilical artery velocity in a pump twin with an adverse pregnancy outcome.

The twin reversed arterial perfusion (TRAP) sequence, also known as fetus acardius, occurs in 0.3 % of monozygotic twin gestations, which amounts to a frequency of about 1 per 35,000 deliveries [1, 2]. There have been only two reports on antenatal three-dimensional (3D) sonographic diagnosis of the TRAP sequence during pregnancy [3, 4]. The HDlive is a new surface render mode involving the use of skin-like colors, and ‘‘its system uses an adjustable light source, giving the operator the opportunity to create lighting and shadowing effects and thereby increasing depth perception’’ [5]. There have been four reports on fetal, placental, and umbilical cord ultrasound images using the 3D HDlive rendering mode [5–8]. Employing 3D HDlive with new skin-like colors, we can achieve a natural and anatomically realistic appearance of the embryo and fetus in utero. However, there has been no reports on 3D HDlive rendering displays of the TRAP sequence in the first trimester of pregnancy. There have been five reports on reverse end-diastolic velocity in umbilical artery velocimetry with an adverse pregnancy outcome at less than 14 weeks of gestation, which suggested that reverse end-diastolic umbilical artery velocity waveforms might be an ominous sign in early pregnancy [9–13]. However, there are no sonographic findings in the first trimester that can help to distinguish between pregnancies resulting in death of the pump twin from those that will survive until prophylactic intervention at 16–18 weeks in TRAP sequence cases [14]. In this report, we present our experience of a TRAP sequence reconstructed employing the 3D HDlive rendering mode, and discuss the reverse end-diastolic blood flow velocity waveform in the umbilical artery of a pump twin with an adverse pregnancy outcome in the first trimester. A 33-year-old pregnant Japanese woman, gravida 1, para 0, was referred to our ultrasound clinic because of a suspected TRAP sequence at 11 weeks and 6 days of gestation. The 2D sonography and the 3D surface rendering mode (Voluson E8, GE Healthcare, Milwaukee, WI, USA) showed a normal pump twin and small acardiac twin with acrania and absence of the heart and upper limbs (Fig. 1). The crown-rump length of the pump twin was 43.3 mm (consistent with the corresponding age), and no gross fetal anomaly was noted. The longitudinal distance between the upper pole and rump of the acardiac fetus was 27.6 mm. The 3D HDlive rendering mode provided anatomically realistic images for TRAP sequence diagnosis (Fig. 2). Color and pulsed Doppler sonography revealed a reverse end-diastolic umbilical artery velocity in the pump twin at 13 weeks and 1 day of gestation (Fig. 3a). There was a single-artery umbilical cord between the placenta and acardiac fetus, and a reversed tiny absent diastolic umbilical artery velocity was noted (Fig. 3b). Fetal demise of the pump twin was confirmed at 14 weeks’ gestation. Delivery C. Tenkumo H. Tanaka M. Ito E. Uketa N. Mori U. Hanaoka K. Kanenishi T. Hata (&) Department of Perinatology and Gynecology, Kagawa University School of Medicine, 1750-1 Ikenobe, Miki, Kagawa 761-0793, Japan e-mail: toshi28@med.kagawa-u.ac.jp

Early onset, severe fetal growth restriction with absent or reversed end‐diastolic flow velocity waveform in the umbilical artery: Perinatal and long‐term outcomes

To assess perinatal and long-term outcomes for pregnancies complicated by early onset, severe fetal growth restriction with absent or reverse end-diastolic flow velocity waveform (AREDF) in the umbilical artery. A retrospective cohort study of 36 singleton pregnancies with AREDF when the estimated fetal weight (EFW) is less than 501 g at presentation. At presentation, the median gestational age and EFW were 24 (18-29) weeks and 364 (167-496) g, respectively. The median interval between presentation and live birth or diagnosis of intrauterine fetal death (IUFD) was 13 (0-60) days. Delivery was for IUFD in 19 cases (53%), fetal indications in 13 cases (36%) and maternal indications in four cases (11%). Caesarean section (CS) was performed for the 17 live births of which 10 (59%) were by classical CS. Of the total cohort, five infants survived to hospital discharge giving an overall perinatal survival rate of 14%. All survivors had short-term morbidity. The cognitive function in four children was assessed as normal at two years of age. One survivor had developmental delay. None of the surviving children had any evidence of cerebral palsy. The overall perinatal survival rate for pregnancies complicated by early onset, severe growth restriction with an EFW of < 501 g and AREDF is low. When delivery occurs for fetal indications, the majority of these women require classical CS. Short-term neonatal morbidity is high though none of the survivors had cerebral palsy.

Absent or reverse end-diastolic flow in the umbilical artery: intellectual development at school age

Objective: This study was designed to establish whether, in growth-retarded fetuses, absent or reverse end-diastolic (ARED) flow velocity in the umbilical artery can be predictive of an increased incidence of long-term neurological and intellectual impairment. Study design: A total of 14 children with intra-uterine growth retardation (IUGR) and ARED flow in the umbilical artery and 11 children without this velocimetric pattern were examined by pediatric neuropsychiatrists at a median age of 8.7 years to evaluate and compare their neurological and intellectual development. Results: The incidence of major neurological sequelae was higher in the children with ARED velocity in the umbilical artery (21%) than in those without this velocimetric pattern (9%), as was the incidence of mild neurological sequelae (35% versus 27%). No differences in mean intelligence quotient (IQ) as evaluated by mean of Intelligence Scale for Children-Revised (WISC-R) scale were found between the two groups of children at school age. Conclusions: Our data demonstrate that Doppler velocimetry in the umbilical artery is a reliable predictor for neurological sequelae when ARED flow is present but cannot be considered a good predictor of intellectual performance at school.

Arterial and Ductus venosus Doppler in Fetuses with Absent or Reverse End-Diastolic Flow in the Umbilical Artery: Longitudinal Analysis

Objective: To evaluate alterations of arterial and ductus venosus blood flow velocities during deterioration and their interdependence. Methods: 37 high-risk pregnancies complicated by umbilical absent or reverse end-diastolic flow velocities (AREDV) were monitored by measurement of the pulsatility index of the umbilical artery, middle cerebral artery and ductus venosus waveforms. Results: The mean observation period was 16.5 days. There was a significant change in the pulsatility of waveforms in all vessels over the observation period. Compared with the ductus venosus, pulsatility of waveforms in the middle cerebral artery diverged from the normal range 2.2 weeks earlier. Increase in pulsatility in the umbilical artery was concomitant with venous but not with cerebral flow alterations. In addition, there was a correlation between the increase of venous but not arterial pulsatility and perinatal acidemia. Variability of pulsatility index values of the umbilical artery and the ductus venosus but not of the middle cerebral artery increased towards delivery. Conclusions: Ductus venosus Doppler allows detection of further deterioration in centralized fetuses with umbilical AREDV. However, striking short-term variability has to be taken into account when considering this parameter.

Arterial and ductus venosus Doppler in fetuses with absent or reverse end-diastolic flow in the umbilical artery: correlation with short-term perinatal outcome.

High perinatal morbidity and mortality rates have been reported in association with absent or reverse end-diastolic flow velocities in the umbilical artery. Doppler of fetal venous blood flow might be a helpful instrument for predicting fetal outcome. However, clinical data addressing this issue are rare. Thus, the aim of this study was to evaluate arterial and ductus venosus blood flow velocities as a predictor of short-term outcome in fetuses with umbilical absent or reverse end-diastolic flow velocities. Thirty-five high-risk single pregnancies complicated by umbilical absent or reverse end-diastolic flow velocities were monitored by serial measurement of the pulsatility index of the umbilical artery, middle cerebral artery, and ductus venosus waveforms over a period of 1-75 days. The mean observation period between first detection of an umbilical absent or reverse end-diastolic flow velocity and delivery was 8.9 days. A significant correlation was found between parameters of short-term perinatal outcome (art. pH, art. base excess, development of intraventricular hemorrhage, mortality) and end-diastolic flow velocity waveform or pulsatility index of the ductus venosus waveform, but not with arterial Doppler parameters. Gestational age proved to be the best predictor for duration of assisted ventilation and development of respiratory distress syndrome. Our results indicate that in high-risk pregnancies with umbilical absent or reverse end-diastolic flow velocities, determination of blood flow velocities in the ductus venosus is a useful additional parameter for prediction of fetal outcome and for timing delivery.

Outcome at school age following antenatal detection of absent or reversed end diastolic flow velocity in the umbilical artery

Aim: To determine whether fetal compromise, manifested by abnormalities of Doppler recordings of umbilical artery velocity waveforms in utero, is associated with neurodevelopmental or educational abnormalities at school age. Methods:...

Reversed end diastolic flow velocity in viable fetuses: is there time to wait for the effect of corticosteroids before delivery?

In severely pre-term, but viable fetuses with reversed end diastolic flow velocity in the umbilical artery, there is time for the effects of corticosteroids before delivery, unless fetal distress occurs.

Impact of reverse end‐diastolic flow velocity in umbilical artery on pregnancy outcome after the 28th gestational week

The aim of this study was to discuss pregnancy outcome in chromosomally and structurally normal fetuses having reverse end-diastolic flow velocity (REDFV) on Doppler umbilical artery velocimetry (DUAV) in the third trimester. DUAV was performed in the high risk pregnancy antepartum fetal surveillance. We excluded gestational age less than 28 weeks, multiple pregnancies, and chromosomal or congenital anomalies. Thirty cases were categorized as having REDFV The pregnancy outcome was investigated in these cases. There were three stillbirths and 12 neonatal deaths, resulting in a perinatal mortality rate of 50%. Twenty-eight patients (93.3%) had complications with preeclampsia (20 of severe degree and eight moderate). Cesarean section was performed on 24 patients (80%) due to acute fetal distress. The mean gestational age at delivery was 31.8+/-3.2 weeks. The mean diagnosis-to-delivery interval was 10+/-8.2 hours. The average birth weight was 970+/-270 gm, 28 (93.3%) were found to be below the 10th percentile of ideal birth weight. An umbilical artery pH less than 7.2 at delivery was found in 12 of 18 examined cases (66.7%). Twelve out of 15 placentae (80%) showed significant infarcts on pathological examination. All newborns (100%) needed admission to the neonatal intensive care unit. REDFV on DUAV represents an ominous and severe fetal condition with an adverse pregnancy outcome, especially in conditions associated with preeclampsia and/or intrauterine growth retardation. Intensive and frequent surveillance and aggressive management at the appropriate time would improve perinatal outcome.

Impact of reverse end-diastolic flow velocity in umbilical artery on pregnancy outcome after the 28th gestational week

Impact of reverse end-diastolic flow velocity in umbilical artery on pregnancy outcome after the 28th gestational week

Reverse end-diastolic uterine artery velocity in a pregnant woman complicated by mild preeclampsia and severe growth retardation

In a pregnant woman with mild preeclampsia and severe intrauterine growth retardation, a reverse end-diastolic flow velocity was detected in both uterine arteries by colour Doppler ultrasound at 30 weeks 4 days of pregnancy. During follow up, both umbilical and internal iliac arteries also showed reverse end-diastolic velocity waveforms and the fetus died in utero at 33 weeks gestation.

Role of Doppler sonography in fetal/maternal medicine

Doppler velocimetry of umbilical, fetal, and uteroplacental vessels provides important information on fetal and uterine hemodynamics and has therefore become one of the most dynamic areas of perinatal research. Examinations of umbilical artery velocity waveforms have gained recognition as a valuable clinical method of fetal surveillance in risk pregnancies. Pathological Doppler findings, especially the finding of absent or reverse end-diastolic (ARED) flow velocity, are associated with fetal hypoxia and adverse outcome of pregnancy. The first follow-up studies indicate that abnormal Doppler findings are associated with impaired postnatal neurological development. Velocimetry of the fetal middle cerebral artery provides important information on redistribution of fetal blood flow in hypoxia; its place in clinics remains to be established. Similarly, more studies are needed to evaluate the use of Doppler velocimetry in labor. Possibly, the Doppler method may facilitate the interpretation of equivocal cardiotocography (CTG) tracings. New evidence has been collected on the correlation between hemodynamic findings and the morphology of the placenta and the placental bed. One of the very important applications of Doppler velocimetry is the evaluation of pharmacological effects on fetal circulation of drugs used for treatment in pregnancy and labor.

Reverse End Diastolic Flow Velocity: Reassuring Biophysical Profile and Acute Fetal Demise

Reverse end diastolic velocity represents the most extreme alteration of the umbilical artery waveform. It has been associated with a high incidence of catastrophic pregnancy outcomes with a stillbirth rate of 33%. We report a case of sudden fetal death within 48 h of a reassuring biophysical profile in a triplet gestation at 31 weeks in which reverse end diastolic velocity was noted in the fetus which died. The postmortem finding of in utero congestive heart failure in this case supports the hypothesis that the alarming rate of stillbirths found in fetuses with absent reverse end diastolic velocity are not necessarily due to asphyxia. This experience illustrates a potential problem with following the fetus who exhibits reverse diastolic flow by traditional markers of fetal well-being such as the biophysical profile.

CK-BB as indicator of prenatal brain-cell injury in fetuses with absent or reverse end-diastolic flow velocities of the umbilical arteries

The purpose of this study is to determine the levels of brain type isoenzyme of creatine kinase (CK-BB) as a possible indicator of a pre-existing intrauterine brain-cell damage in cord blood sera of fetuses with preceding absent or reverse end-diastolic flow velocities of the umbilical arteries (AREDFV). CK-BB isoenzyme activities were determined in umbilical cord sera of 13 newborn infants with preceding AREDFV and in 14 fetuses with low end-diastolic flow velocities (LEDFV) of the umbilical arteries. 50 newborn infants with elective cesarean section and normal umbilical artery blood flow velocity waveforms were used as controls. Two-tailed Student's t-test and Fischer's exact test were used for statistical evaluation of the results. CK-BB isoenzyme activity did not depend on gestational age. Fetuses with AREDFV showed a significant increase in CK-BB values, whereas fetuses with LEDFV had CK-BB activities within the normal range of the controls. The elevated CK-BB values of the AREDFV group were not correlated with fetal acidosis at birth. Brain-cell injury with leakage of CK-BB isoenzyme might be present in fetuses with AREDFV even before (preterm) delivery.

Reverse end-diastolic umbilical artery velocity in a case of intrauterine fetal death at 14 weeks' gestation

A case of intrauterine fetal death at 14 week's gestation in a mother with systemic lupus erythematosus is described. Doppler ultrasonography performed within 24 hours before fetal death showed reverse end-diastolic flow velocities on umbilical artery velocity waveforms. The placental alteration causing this early gestation is discussed.

Condition at birth of infants with previously absent or reverse umbilical artery end-diastolic flow velocities

In a case control study we assessed 47 fetuses with absent or reverse end-diastolic flow velocities (AREDFV) of the umbilical artery with respect to the mode of delivery, fetal acidosis, and abnormal neurological evaluations at the time of discharge from the department of pediatrics. We also studied a control group which was matched for gestational age and had normal umbilical artery flow velocity waveforms. Fetuses with AREDFV were delivered almost exclusively by cesarean section which was usually done for fetal distress. The number of fetuses with abnormal neurological signs was significantly increased compared to the control group. Fetuses with AREDFV showed an increased incidence of fetal acidosis. Forty per cent of these fetuses were delivered within one day of the first abnormal flow measurement; Sixty per cent were observed clinically for up to four weeks before delivery.

Blood flow velocity waveforms of the middle cerebral artery and abnormal neurological evaluations in live-born fetuses with absent or reverse end-diastolic flow velocities of the umbilical arteries

We studied 37 fetuses with absent or reverse end-diastolic flow velocities (AREDFV) of the umbilical arteries with respect to the mode of delivery, fetal acidosis, resistance index of the middle cerebral arteries, and abnormal neurological evaluation at the time of discharge from the department of pediatrics. A control group with normal umbilical artery flow velocity waveforms was matched for gestational age. Fetuses with AREDFV were delivered almost exclusively by cesarean section, in most cases due to fetal distress. Metabolic changes with decreased base excess values were found more often in fetuses with AREDFV, but no difference could be detected with respect to severe fetal acidosis. The number of fetuses with abnormal neurological evaluations during the first 6 months of life was significantly higher in cases with AREDFV than in the control group. More than two thirds of the fetuses with AREDFV showed an abnormal blood flow velocity waveform of the middle cerebral arteries with elevated end-diastolic flow velocities. The combination of extreme premature delivery before 28 weeks of gestation, severe idiopathic respiratory distress syndrome, and a resistance index of the middle cerebral arteries under the 5th percentile seems to be a risk factor for early neurological morbidity in fetuses with AREDFV. Premature delivery of fetuses with AREDFV — as we did during our study in order to prevent intra-uterine death or fetal asphyxia — should therefore be critically regarded in cases under 28 weeks of gestational age and abnormal flow velocity waveforms of the middle cerebral arteries.

Reverse end-diastolic flow velocity on umbilical artery velocimetry in high-risk pregnancies: An ominous finding with adverse pregnancy outcome

Systolic/diastolic ratios of umbilical velocimetry have been used to assess downstream placental vascular resistance. Reverse end-diastolic flow velocity during end diastole suggests extreme abnormality in waveform and resistance. We reviewed our experience of patients showing reverse end-diastolic flow velocity over a 2 1/2-year period. Out of 550 high-risk patients studied with umbilical velocimetry over this period, 12 patients showed the finding. All patients were delivered of small for gestational age fetuses and the perinatal mortality in this group was 50%. There was also significant perinatal morbidity as judged by cesarean section performed because of fetal distress, low Apgar scores, days in neonatal intensive care, prematurity, placental infarcts, and lethal anomalies. These findings suggest that reverse end-diastolic velocity on umbilical velocimetry is associated with catastrophic perinatal outcome, and aggressive perinatal management may be advised in this group of patients.