Uterine Artery Doppler Waveforms Research Articles

Third‐Trimester Abnormal Uterine Artery Doppler Findings Are Associated With Adverse Pregnancy Outcomes

To evaluate the association between third-trimester abnormal uterine artery Doppler findings and pregnancy outcomes. A prospective study was designed, including 198 consecutive singleton pregnancies between 27 and 41 weeks' gestation. In the study population, 144 had normal uterine artery Doppler waveforms, 37 had unilateral pathologic waveforms, and 17 had bilateral pathologic waveforms. Eighty patients had intrauterine growth restriction (IUGR), preeclampsia toxemia, or both, and 118 had no complications and served as a control group. The uterine artery Doppler waveform was considered abnormal when a notch or pulsatility index above the 90th percentile was noted. In patients with bilateral pathologic uterine artery Doppler waveforms, the rates of cesarean delivery, small-for-gestational-age (SGA) neonates, preterm delivery, and low Apgar scores were increased compared to patients with normal or pathologic unilateral waveforms (P = .009; P > .001; P = .007; P > .001, respectively). The incidence rates for SGA neonates, cesarean delivery, and preterm delivery were significantly higher among patients without IUGR or preeclampsia toxemia when associated with pathologic bilateral waveforms in comparison to normal waveforms (P = .01 for all). A bilateral pathologic waveform was found to be an independent risk factor for cesarean delivery and SGA neonates. The incidence rates for SGA neonates and preterm delivery were significantly higher among patients with IUGR and/or preeclampsia toxemia when associated with bilateral abnormalities in comparison to normal waveforms (P = .01 for both). Third-trimester abnormal uterine artery Doppler findings are associated with worse perinatal outcomes among patients both with and without pregnancy complications.

Maternal sigara kullamının doppler ölçümleri üzerine etkisinin araştırılması

Objective: It is suggested that smoking has adverse effects on pla- centa development by decreasing placental vascularization. Cigarette exposure is associated with intrauterine and perinatal death, preterm labor, ablatio placenta, placenta previa and intrauterine growth retardation. The aim of this study is to inves- tigate the effect of smoking on fetal Doppler ultrasound wave- forms and its pathophysiological relationship with fetal birth weight. Methods: The study was conducted in Gynecology and Obstetrics Department of Dokuz Eylul University between January 13th and 24th April 2011. One hundred nineteen single- ton pregnancies were included to the study. Group 1 consisted of 22 patients who were smoking 4-10 cigarettes daily. Group 2 con- sisted of 97 non-smoker patients before and during their pregnan- cies. Patients' maternal uterine, fetal umbilical and fetal middle cerebral arteries Doppler measurements were done on 37th week of gestation. Results: Weight gain in the Group 1 was statistically higher than non-smoking patients. There were statistically significant changes in fetal Doppler measurements, but no difference was found in maternal Doppler waveforms between the two groups. Maternal uterine artery Doppler waveforms were similar in both groups; in fact fetal umbilical artery and middle cerebral artery waveforms were statistically higher for Group 1. Conclusion: Cigarette contains nicotine, carbon monoxide and thousands of other toxic chemicals. Carbon monoxide reduces the oxygen transfer to the fetus. Chronic tobacco use decreases pla- cental blood flow, hypoxic pathologic environment occurs, and changes appear on fetal Doppler ultrasound waveforms.

Association between first trimester vaginal bleeding and uterine artery Doppler measured at second and third trimesters of pregnancy

Objective: To evaluate the prevalence of first trimester vaginal bleeding among patients with abnormal second and third trimester uterine artery Doppler.Methods: A prospective study of patients with a uterine artery Doppler measurement between 27 and 42 weeks’ gestation was undertaken. A comparison was made between two groups: patients with and without first trimester vaginal bleeding. Abnormal uterine artery Doppler was defined as PI >95th% or the presence of a diastolic notch.Results: Of the 277 patients that were included in the study, 65 (23%) had first trimester vaginal bleeding. No differences were noted in uterine artery Doppler waveforms among patients with and without first trimester vaginal bleeding.Among patients with first trimester vaginal bleeding, 9 (14%) had a bilateral uterine artery notch and 56 (86%) did not, compared with 51 (24%) and 161 (76%), in the control group, respectively. Patients with first trimester vaginal bleeding, and a bilateral uterine artery notch had significantly higher rates of small for gestational age neonates, low-Apgar scores (<7) at one minute and cesarean deliveries compared to patients with first trimester vaginal bleeding who did not have bilateral uterine artery notch.Conclusion: First trimester vaginal bleeding was not associated with a higher incidence of abnormal uterine artery waveforms or with placental related conditions. However, adverse perinatal outcomes were found when first trimester vaginal bleeding was associated with second and third trimester bilateral uterine artery notchs.

Comparison of Wavelet Transform and Time-Domain Analysis of Second Trimester Uterine Artery Doppler Waveforms in Screening for Pre-Eclampsia

The aim of this study was to compare time-domain waveform analysis of second-trimester uterine artery Doppler using the resistance index (RI) with waveform analysis using a mathematical tool known as wavelet transform for the prediction of pre-eclampsia (PE). This was a retrospective, nested case-cohort study of 336 women, 37 of whom subsequently developed PE. Uterine artery Doppler waveforms were analysed using both RI and waveform analysis. The utility of these indices in screening for PE was then evaluated using receiver operating characteristic curves. There were significant differences in uterine artery RI between the PE women and those with normal pregnancy outcome. After wavelet analysis, significant difference in the mean amplitude in wavelet frequency band 4 was noted between the 2 groups. The sensitivity for both Doppler RI and frequency band 4 for the detection of PE at a 10% false-positive rate was 45%. This small study demonstrates the application of wavelet transform analysis of uterine artery Doppler waveforms in screening for PE. Further prospective studies are needed in order to clearly define if this analytical approach to waveform analysis may have the potential to improve the detection of PE by uterine artery Doppler screening.

ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics

<scp>ISUOG</scp> Practice Guidelines: use of Doppler ultrasonography in obstetrics

Predicting Obstetric Vasculopathies through Study of Diastolic Notch and other Indices of Resistance to Blood Flow in Uterine Artery

ABSTRACTObstetric vasculopathies are a set of apparently heterogeneous and poorly understood conditions. Conditions like recurrent miscarriages due to fetal demise, pre-eclampsia, IUGR, recurrent still births and accidental hemorrhage all seem to have the same underlying etiopathology. They are grouped into one large set coined as ‘Obstetric Vasculopathies’. Resistance to blood flow in the uterine arteries can be important and effective method to predict obstetric vasculopathies (except recurrent miscarriages). Resistance to this blood flow can be measured by the presence (and subsequent disappearance) of diastolic notch as well as the standard color Doppler indices namely Pulsatility Index (PI), Resistance Index (RI) and Systolic: Diastolic (S: D) ratio. In normal pregnancy almost always at 12 to 14 weeks of duration, the uterine artery shows presence of a diastolic notch. In high-risk subjects, disappearance of diastolic notch at midtrimester in uterine artery Doppler waveform analysis if used alone may not be a good screening method for obstetric vasculopathies. However, the combination of a diastolic notch and an abnormal resistance index in both uterine arteries at 20 weeks gestation is more accurate indicator in predicting severe pregnancy complications. These subjects are almost eight times more likely to develop either: Clinically significant hypertension and/or deliver prior to 32 weeks and/or have a perinatal demise and/or have an Infant with a birth weight of less than 1500 gm. Bilateral or Unilateral: Studying bilateral uterine artery seems to be more accurate that unilateral artery for prediction of obstetric vasculopathies. Prediction in I-Trimester: Disappearance of uterine artery diastolic notch in combination with other parameters seems to be a good test for prediction of obstetric vasculopathies particularly PIH and IUGR in I-Trimester. The advantage of such an early allows an early instituting of preventive measures. Notch Depth Index (NDI): It is calculated as the depth of the diastolic notch divided by the maximal diastolic velocity. The NDI value in the second trimester is associated with the later onset of pre-eclampsia, and is clinically more useful in predicting pre-eclampsia than the two conventional indices. Abnormal maternal uterine artery Doppler in association with elevated maternal serum AFP, HCG, Inhibin A or decreased PAPP-A identifies a group of subjects at greater risk of IUGR and gestational hypertension with proteinuria. Lowdose aspirin administered as early as 14 to 16 weeks of gestation to pregnant subjects at high risk of pre-eclampsia with abnormal uterine Doppler findings may reduce or modify the course of severe pre-eclampsia and may help in prevention of IUGR.How to cite this articleDesai P. Predicting Obstetric Vasculopathies through Study of Diastolic Notch and other Indices of Resistance to Blood Flow in Uterine Artery. Int J Infertility Fetal Med 2013;4(1):24-30.

OP21.08: Influence of the Doppler sample gate location in the uterine artery Doppler waveform analysis

OP21.08: Influence of the Doppler sample gate location in the uterine artery Doppler waveform analysis

Beyond the placental bed: Placental and systemic determinants of the uterine artery Doppler waveform

The uterine artery Doppler waveform has been extensively investigated, though its widespread clinical use as a predictor of adverse pregnancy outcome remains under debate. The determinants of the waveform have classically been ascribed to transformation of the spiral arteries and the development of a low resistance uteroplacental circulation, failure of which predisposes to pre-eclampsia, fetal growth restriction and other adverse outcomes. It has become increasingly evident that although spiral artery transformation determines in some part the characteristics of the Doppler waveform, factors pertaining to maternal vascular and endothelial function are also important.

Pulse pressure waveform analysis compared to doppler ultrasonography as a screening tool for hypertensive pregnancy

Pre-eclampsia is a hypertensive disorder unique to pregnancy. Accurate prediction of the development of pre-eclampsia is still elusive. Uterine artery Doppler provides information regarding blood flow within the vascular system....

Sildenafil Citrate Rescues Fetal Growth in the Catechol- O -Methyl Transferase Knockout Mouse Model

Preeclampsia and fetal growth restriction are responsible for the majority of maternal and perinatal morbidity and mortality associated with complicated pregnancies. Although their etiologies are complex and multifactorial, both are associated with increased uterine artery resistance. Sildenafil citrate is able to rescue the dysfunction observed ex vivo in uterine arteries of women with preeclampsia. The ability of sildenafil citrate to increase uterine artery vasodilation, thereby decreasing uterine artery resistance and, hence, ameliorated preeclampsia and fetal growth restriction, was tested in a mouse model of preeclampsia, the catechol-O-methyl transferase knockout mouse (COMT(-/-)). COMT(-/-) and C57BL/6J mice were treated (0.2 mg/mL in drinking water, n=6-12) from gestational day 12.5 to 18.5. Measures of pup growth, including body weight, crown/rump length, and abdominal circumference, were reduced in COMT(-/-) mice; this was normalized after treatment with Sildenafil. COMT(-/-) mice also demonstrated abnormal umbilical Doppler waveforms, including reverse arterial blood flow velocity. This was normalized after treatment with Sildenafil. Abnormal uterine artery Doppler waveforms were not demonstrated in COMT(-/-) mice, although ex vivo responses of uterine arteries to phenylephrine were increased; moreover, treatment with Sildenafil did improve ex vivo sensitivity to an endothelium-dependent vasodilator. The data presented here demonstrate that Sildenafil can rescue pup growth and improve abnormal umbilical Doppler waveforms, providing support for a potential new therapeutic strategy targeting fetal growth restriction.

Transdermal nitroglycerin in patients with severe pre‐eclampsia with placental insufficiency: effect on uterine, umbilical and fetal middle cerebral artery resistance indices

To evaluate the effect of transdermal nitroglycerin on Doppler velocity waveforms of the uterine, umbilical and fetal middle cerebral arteries in patients with severe pre-eclampsia. This was a prospective study of 30 singleton pregnancies (gestational age range: 24-31 weeks) with severe pre-eclampsia and abnormal uterine and umbilical artery Doppler waveforms. We compared maternal blood pressure as well as the resistance index (RI) and the pulsatility index (PI) of the uterine, umbilical and fetal middle cerebral arteries before and after application of a transdermal nitroglycerin patch (average dose 0.4 mg/h) for a period of 3 days. Intra-day comparisons before and after administration of nitroglycerin and a comparison between days 0 (no patch) and 3 after administration of the first dose of nitroglycerin were performed using ANOVA for paired samples. A significant decrease in the PI and RI of the uterine (25.3 ± 4.9% and 21.2 ± 6.2%, respectively, P < 0.001) and umbilical (23.1 ± 6.9% and 19.7 ± 6.1%, respectively, P < 0.001) arteries was noted when comparing the first day without medication against the third day with the patch. No significant change in the PI and RI of the middle cerebral artery was observed. The mean arterial blood pressure decreased from 119.5 ± 4.5 mmHg to 114.8 ± 4.4 mmHg (P < 0.05). The use of transdermal nitroglycerin in patients with severe pre-eclampsia is associated with a significant reduction in the RI and PI of the uterine and umbilical arteries, as well as of maternal blood pressure. Transdermal nitroglycerin does not affect the RI and PI of the fetal middle cerebral artery.

OP27.09: Comparison of wavelet and conventional analysis of uterine artery Doppler waveforms in pre‐eclampsia screening

OP27.09: Comparison of wavelet and conventional analysis of uterine artery Doppler waveforms in pre‐eclampsia screening

Preeclampsia, a disease of the maternal endothelium: the role of antiangiogenic factors and implications for later cardiovascular disease.

Preeclampsia is a clinical syndrome defined as the new onset of hypertension and proteinuria during the second half of pregnancy.1 It afflicts 3% to 5% of pregnancies and is a leading cause of maternal mortality, especially in developing countries.2,3 Because the only known remedy is delivery of the placenta, in developed countries preeclampsia is an important cause of premature delivery, usually medically indicated for the benefit of the mother. This results in infant morbidity and substantial healthcare expenditure.4 Despite the considerable morbidity and mortality, the cause of preeclampsia has remained enigmatic. Both hypertension and proteinuria implicate the endothelium as the target of the disease. The hypertension of preeclampsia is characterized by peripheral vasoconstriction and decreased arterial compliance.5,6 The proteinuria of preeclampsia is associated with a pathognomonic renal lesion known as glomerular endotheliosis, in which the endothelial cells of the glomerulus swell and endothelial fenestrations are lost.7,8 Podocyturia has been recently associated with preeclampsia during clinical disease9; however, whether this is the cause or effect of proteinuria is unknown. The glomerular filtration rate is decreased compared with normotensive pregnant women; in rare cases, acute renal failure may develop. Preeclampsia is a systemic vascular disorder that may also affect the liver and the brain in the mothers. When the liver is involved, women may present with abdominal pain, nausea, vomiting, and elevated liver enzymes. Pathological examination of the liver reveals periportal and sinusoidal fibrin deposition and, in more extreme cases, hemorrhage and necrosis.10 The severe preeclampsia variant HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) occurs in ≈20% of women with severe preeclampsia,11 and is named not only for the liver involvement, but also for the disorder of the coagulation system that develops.12 Approximately 20% of …

Clinical risk prediction for pre-eclampsia in nulliparous women: development of model in international prospective cohort

Objectives To develop a predictive model for pre-eclampsia based on clinical risk factors for nulliparous women and to identify a subgroup at increased risk, in whom specialist referral might be...

OP01.06: Cardiovascular parameters in the prediction of mortality in early‐onset intrauterine growth restriction

Methods: We examined 156 pregnant women in The Department of the Fetal Medicine and Gynecology of Medical University of Lodz in the years 2006–2009. At each pregnant woman were estimated biochemical markers in the first (PAPP-A + β-hCG) and in the second trimester (AFP, β-hCG, uE3triple test), they underwent 3 ultrasound scans (first at 11 to 13+6 weeks, second at 15 to 20 weeks and third at 22 to 27 weeks of pregnancy) with uterine artery Doppler examination. We observed the follow up of the pregnancies due to the PIH and IUGR. 2 study groups included 28 patients with PIH and 14 patients with IUGR, in the control group were 114 patients with uncomplicated pregnancies. Results: In study groups we observed: higher maternal serum concentration of β-hCG, higher percentage of the positive results biochemical prenatal tests and abnormal uterine artery Doppler waveform positive triple test was the strongest predictor of PIH and IUGR (PPV = 60.87% for PIH and PPV = 30.77% for IUGR). Conclusions: Biochemical markers and abnormal uterine artery Doppler waveform are associated with PIH and IUGR. These parameters can create the test showing the high-risk group of PIH and IUGR in pregnancy. These studies were carried out thanks to Science and Higher Education Ministry funds – grant registration no: N406 044 31/1354.

Mutation analysis of the growth factor genes PlGF, Flt1, IGF-I, and IGF-IR in intrauterine growth restriction with abnormal placental blood flow

Objective. The objective of our study was to investigate a possible role of pathogenic mutations in the growth factor genes insulin like growth factor I (IGF-I) and placental growth factor (PlGF) and their receptors IGF-IR and fms-like tyrosine kinase 1 (Flt1) in the pathogenesis of placental dysfunction.Methods. We analyzed two patient groups with IUGR (intrauterine growth restriction), 18 mother–child pairs with absent or reversed enddiastolic flow (ARED) in the umbilical artery and 12 mother–child pairs with preserved enddiastolic flow (PED) in the presence of a bilateral abnormal uterine artery Doppler waveform (Notching). The control group comprised of 50 healthy mother–child pairs.Results. Sequencing did not show a pathogenic mutation in any of the analyzed genes. However, we detected three novel polymorphisms in the IGF-IR gene. In addition, we identified one unknown polymorphism in exon 1 of the non-coding region of PlGF and 2 novel variants in exons 1 and 6 of Flt1.Conclusion. In summary, our results do not provide evidence for a relevant role of pathogenic mutations in the genes IGF-I, IGF-IR, PlGF, and Flt1 in the etiology of IUGR with ARED or PED flow.

Duration of sexual relationship and its effect on preeclampsia and small for gestational age perinatal outcome

The aim of this study was to determine if women with preeclampsia or delivering small for gestational age (SGA) babies are more likely to have a short duration of sexual relationship compared with those who have uncomplicated pregnancies. In a prospective cohort study, 2507 nulliparous women with singleton pregnancies were interviewed at 15+/-1 weeks gestation about the duration of their sexual relationship with the biological father. Short duration of sexual relationship (< or =6 months, < or =3 months, or first intercourse) was compared between women with preeclampsia (N=131) or SGA babies (N=263) and those with uncomplicated pregnancies (N=1462). Short duration of sexual relationship was more common in women with preeclampsia compared with uncomplicated pregnancies (< or =6 months 14.5% versus 6.9%, adjusted odds ratio [adjOR] 1.88, 95% CI 1.05-3.36; < or =3 months 6.9% versus 2.5%, adjOR 2.32, 95% CI 1.03-5.25; first intercourse 1.5% versus 0.5%, adjOR 5.75, 95% CI 1.13-29.3). Although the total number of semen exposures was lower in SGA, SGA was not associated with a shorter duration of sexual relationship. On post hoc analysis, the subgroup of SGA with abnormal uterine artery Doppler at 20 weeks (N=58) were more likely to have had a short sexual relationship compared with controls (< or =6 months adjOR 2.33, 95% CI 1.09-4.98; < or =3 months adjOR 3.22, 95% CI 1.18-8.79; first intercourse adjOR 8.02, 95% CI 1.58-40.7). We conclude that compared to uncomplicated pregnancies, short duration of sexual relationship is more common in women who develop preeclampsia and women with abnormal uterine artery Doppler waveforms who deliver an SGA baby.

Changes in Doppler flow velocity waveforms and fetal size at 20 weeks gestation among cigarette smokers

To compare umbilical and uterine artery Doppler waveforms and fetal size at 20 weeks between smokers and nonsmokers. Prospective cohort study. Auckland, New Zealand and Adelaide, Australia. Nulliparous participants in the Screening for Pregnancy Endpoints (SCOPE) study. Self-reported smoking status was determined at 15 +/- 1 weeks' gestation. At the 20 +/- 1 week anatomy scan, uterine and umbilical Doppler resistance indices (RI) and fetal measurements were compared between smokers and nonsmokers. Umbilical and mean uterine artery Doppler RI values, abnormal umbilical and uterine Doppler (RI > 90th centile) and fetal biometry. Among the 2459 women, 248 (10%) were smokers. Smokers had higher umbilical RI [0.75 (SD 0.06) versus 0.73 (0.06), P < 0.0001] and mean uterine RI [0.59 (0.09) versus 0.56 (0.10), P < 0.0001]. They were twice as likely to have an abnormal umbilical Doppler at 20 weeks compared with nonsmokers [n = 35 (14.6%) versus n = 156 (7.2%), OR 2.21, 95% CI 1.49-3.27]. This effect remained significant after adjusting for age, ethnicity, marital status, employment and BMI (adjusted OR 1.62, 95% CI 1.03-2.54). Smokers were more likely to have an abnormal mean uterine RI [n = 33 (13.7%) versus n = 198 (9.2%), OR 1.57, 95% CI 1.06-2.33], but this association was not significant after adjusting for confounders. Fetuses of women who smoked had a small reduction in femur length and estimated weight compared with nonsmokers. At 20 weeks' gestation, women who smoke have higher umbilical artery RI, a surrogate measure for an abnormal placental villous vascular tree. This may contribute to later fetal growth restriction among smokers. Further research is needed to explore the clinical significance of these findings.

Maternal endothelial function and serum concentrations of placental growth factor and soluble endoglin in women with abnormal placentation

To determine whether maternal serum concentrations of placental growth factor (PlGF) and soluble endoglin (sEng) are altered in women who subsequently develop pre-eclampsia (PE) or have small-for-gestational-age (SGA) infants, and whether these changes are associated with maternal endothelial dysfunction. Maternal serum PlGF and sEng were measured in two groups of pregnant women at 23-25 weeks' gestation: Group A (n = 40), with normal uterine artery Doppler waveforms and Group B (n = 43) with abnormal Doppler. Maternal endothelial dysfunction was assessed by flow-mediated dilatation (FMD) of the brachial artery. Comparisons between groups were performed using one-way analysis of variance. In Group B, 16 women had normal outcome, 15 delivered SGA infants and 12 developed PE. Women who developed PE had lower levels of PlGF (154.8 +/- 150.8 vs. 423.3 +/- 230.5 pg/mL; P < 0.001) (data given as mean +/- SD) and higher levels of sEng (8.1 (7.0-14.1) vs. 6.5 (4.9-7.9) pg/mL; P < 0.05) (data given as median (interquartile range)) than Group A. Similar were the findings in women who delivered SGA infants. In women who subsequently developed PE, there was no correlation between FMD and either PlGF or sEng. Maternal serum concentrations of PlGF and sEng are altered in women who develop PE. However, these alterations do not correlate directly with maternal endothelial dysfunction.

Circulating levels of adiponectin and leptin at 23–25 weeks of pregnancy in women with impaired placentation and in those with established fetal growth restriction

Adiponectin and leptin, two adipose-tissue-derived proteins, have been reported to be elevated in women with established PE (pre-eclampsia). The aim of the present study was to investigate whether alterations in adiponectin and leptin levels predate the development of PE and FGR (fetal growth restriction) in women at increased risk of these complications, as assessed by Doppler examination of the uterine arteries during the second trimester of pregnancy. We also sought to investigate the circulating levels of adiponectin and leptin in women with established severe early-onset FGR. The study included three groups of pregnant women at 23-25 weeks: Group A (n=44) with normal uterine artery Doppler waveforms, Group B (n=49) with abnormal Doppler waveforms and normal fetal growth at the time of the examination, and Group C (n=15) with established severe FGR and abnormal Doppler waveforms. All women had plasma adiponectin and leptin measured by sensitive immunoassays. In Group B, 19 women had a normal outcome, 17 delivered infants with FGR and 13 developed PE. The women who developed PE delivered smaller babies earlier than women with a normal outcome (P<0.001). There were no significant differences in adiponectin levels between any of the groups (overall P=0.3). Leptin concentrations, expressed as MoM (multiples of the median) of Group A, were higher in women in Group C, i.e. established severe FGR at 2.5 (1.2-2.7) MoMs (overall P<0.001), compared with all of the other groups and subgroups. In conclusion, we found that, in pregnancies complicated by severe early-onset FGR, the maternal plasma concentration of leptin is twice as high as in normal pregnancies. However, the second trimester levels of maternal plasma adiponectin and leptin in pregnancies that subsequently develop PE and/or FGR are not significantly different from normal and, consequently, it is unlikely that these markers will be useful as predictors of these pregnancy complications.