color doppler in fetal hypoxia

COLOR DOPPLER IN FETAL GROWTH RESTRICTION AND

HYPOXIA

COLOR DOPPLER IN FETAL GROWTH RESTRICTION AND

HYPOXIA

narendra malhotra

jaideep malhotraneharika malhotra bora,rishabh bora,

keshav malhotra

Acknowledgments:

asim kujak,ashok khurana,jayprakash shah

narendra malhotra

jaideep malhotraneharika malhotra bora,rishabh bora,

keshav malhotra

Acknowledgments:

asim kujak,ashok khurana,jayprakash shah

www.malhotrahospitals.comwww.rainbowhospitals.org

IMPORTANCEIMPORTANCE

THE ACCURACY OF DOPPLER VELOCIMETRY IN

CONJUNCTION WITH 2D ULTRASOUND AND

COLOR FLOW MAPPING IS NOW REGARDED AS

AN INDISPENSABLE COMPONENT OF A

PREGNANCY SONOGRAM

THE ACCURACY OF DOPPLER VELOCIMETRY IN

CONJUNCTION WITH 2D ULTRASOUND AND

COLOR FLOW MAPPING IS NOW REGARDED AS

AN INDISPENSABLE COMPONENT OF A

PREGNANCY SONOGRAM

PERSPECTIVEPERSPECTIVE

EXCLUDE FETAL ANOMALIES

EVALUATE FETAL SIZE

QUANTIFY LIQUOR AMNII

EVALUATE BIOPHYSICAL PARAMETERS

ASSESS PLACENTA, CORD & CERVIX

EXCLUDE FETAL ANOMALIES

EVALUATE FETAL SIZE

QUANTIFY LIQUOR AMNII

EVALUATE BIOPHYSICAL PARAMETERS

ASSESS PLACENTA, CORD & CERVIX

COLOR DOPPLER STUDIESCOLOR DOPPLER STUDIES

IDENTIFY THE FETUS AT RISK FOR

DAMAGE OR DEATH IN UTERO

IDENTIFY THE FETUS AT RISK FOR

DAMAGE OR DEATH IN UTERO

ESTABLISHED FACTSESTABLISHED FACTS

ARE AN ESTABLISHED TOOL TO ASSESS

MODE AND TIMING OF DELIVERY

PREDICT REASONABLY WELL THE FETUS

AT RISK FOR A GROWTH DISORDER

IMPROVE PREGNANCY OUTCOMES

ARE AN ESTABLISHED TOOL TO ASSESS

MODE AND TIMING OF DELIVERY

PREDICT REASONABLY WELL THE FETUS

AT RISK FOR A GROWTH DISORDER

IMPROVE PREGNANCY OUTCOMES

COLOR DOPPLER STUDIESCOLOR DOPPLER STUDIES

FETAL WELL-BEING

RISK OF CONTINUED INTRAUTERINE EXISTENCE

FETAL WELL-BEING

RISK OF CONTINUED INTRAUTERINE EXISTENCE

ESTABLISHED UTILITYESTABLISHED UTILITY

HIGH RISK PREGNANCYHIGH RISK PREGNANCY

LOW RISK PREGNANCYLOW RISK PREGNANCY

IDENTIFYING A SUB-GROUP OF FETUSES

THAT NEED INCREASED SURVEILLANCE

IDENTIFYING A SUB-GROUP OF FETUSES

THAT NEED INCREASED SURVEILLANCE

REQUIREMENTSREQUIREMENTS

HIGH RESOLUTION GRAY SCALE 2D IMAGE ( 2D US )

SUPERIMPOSED COLOR FLOW MAP ( CFM )

DOPPLER SPECTRAL ANALYSIS ( dD )

HIGH RESOLUTION GRAY SCALE 2D IMAGE ( 2D US )

SUPERIMPOSED COLOR FLOW MAP ( CFM )

DOPPLER SPECTRAL ANALYSIS ( dD )

COLOR DOPPER IN IUGRCOLOR DOPPER IN IUGR

METHODOLOGY

NORMAL FETAL CICULATION

HYPOXIA-REDISTRIBUTION MECHANISM IN IUGR

MANAGEMENT STATEGIES

METHODOLOGY

NORMAL FETAL CICULATION

HYPOXIA-REDISTRIBUTION MECHANISM IN IUGR

MANAGEMENT STATEGIES

PART I :METHODOLOGYPART I :METHODOLOGY

3.5- or 5-MHz curved-array transducer Spatial peak temporal average intensities <100

mW/cm2. High-pass filter - 125 Hz. Size of the sample volume adapted to the

vessel diameter to cover it entirely. Recordings for measurements were obtained in

the absence of fetal breathing movements and fetal heart R between 120 -160 bpm

The angle between the ultrasound beam and the direction of blood flow was always less than 50°.

3.5- or 5-MHz curved-array transducer Spatial peak temporal average intensities <100

mW/cm2. High-pass filter - 125 Hz. Size of the sample volume adapted to the

vessel diameter to cover it entirely. Recordings for measurements were obtained in

the absence of fetal breathing movements and fetal heart R between 120 -160 bpm

The angle between the ultrasound beam and the direction of blood flow was always less than 50°.

Principles of Color DopplerPrinciples of Color Doppler

Color Doppler Power Doppler

Principles of Color DopplerPrinciples of Color Doppler

Quantitative analysis

Doppler indices

Cuningham FG, MacDonald PC, Leveno K, Gant NF, Gilstrap LC II Williams Obstetrics 1993

Placenta

The Supply Line to the Human Fetus

Small for Gestational Age

Nutritional

Placental

Environmental

Endocrine

Infection/Inflammation

Genetic

Maternal

Unknown

Sadler TW Lagman’s Medical Embryology 1990

Umbilicalvessels Chorionic

vesselsChorionic

plateAmnion

Spiralartery

Placentalseptum

Basalplate

Uteroplacentalveins

NORMAL FETAL CIRCULATIONNORMAL FETAL CIRCULATION

FETAL HYPOXIA-ACIDOSISFETAL HYPOXIA-ACIDOSIS

AORTIC BODY CHEMORECEPTOR STIMULATION

AORTIC BODY CHEMORECEPTOR STIMULATION

REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT

REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT

REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT

REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT

INCREASED FLOWINCREASED FLOWDECREASED FLOWDECREASED FLOW

KIDNEYS

(OLIGURIA)

(OLIGOAMNIOS) LUNGS

(RDS) GUT

(NEC) LIVER/MUSCLE

(IUGR)BODY FAT/GLYCOGEN STORES

KIDNEYS

(OLIGURIA)

(OLIGOAMNIOS) LUNGS

(RDS) GUT

(NEC) LIVER/MUSCLE

(IUGR)BODY FAT/GLYCOGEN STORES

BRAIN BRAIN

ADRENALS ADRENALS

HEART HEART

Organ-sparing effects Organ-sparing effects

Heart and brain sparing act synergistically with venous and arterial redistribution.

Both of these organs derive their blood supply from the left ventricle.

Vasodilatation at the organ level acts synergistically to increase organ blood flow.

Heart and brain sparing act synergistically with venous and arterial redistribution.

Both of these organs derive their blood supply from the left ventricle.

Vasodilatation at the organ level acts synergistically to increase organ blood flow.

Doppler vessels to be studiedDoppler vessels to be studied

MATERNAL SIDE

Uterine artery PLACENTAL SIDE

Umbilical a FETAL SIDE

Arterial:mca,fetal a,renal and others

Venous:ductus,hepatic,umbilical

Fetal echocardiography

MATERNAL SIDE

Uterine artery PLACENTAL SIDE

Umbilical a FETAL SIDE

Arterial:mca,fetal a,renal and others

Venous:ductus,hepatic,umbilical

Fetal echocardiography

UTERINE ARTERIESUTERINE ARTERIES

REFLECTS : TROPHOBLASTIC INVASION

END POINTS :

ELEVATED RESISTIVE INDICES (>2SD)

PERSISTENT DIASTOLIC NOTCHING

PRESENCE OF SYSTOLIC NOTCHING

MAJOR LEFT TO RIGHT VARIATION

REFLECTS : TROPHOBLASTIC INVASION

END POINTS :

ELEVATED RESISTIVE INDICES (>2SD)

PERSISTENT DIASTOLIC NOTCHING

PRESENCE OF SYSTOLIC NOTCHING

MAJOR LEFT TO RIGHT VARIATION

Utero placental circulation

SITE:Uterine ArterySITE:Uterine Artery

Empty BladderInside down

NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREG

NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREG

Diastolic Notch(irrespective of the RI)

Normal uterine artery Doppler Abnormal uterine artery Doppler

Abnormal Uterine Artery Doppler Velocimetry

Utero placental circulationUtero placental circulation

Conversion of spiral artery into utero placental vessel

Brosens et al

Uterine ArteryUterine Artery

Normal impedance to flow the uterine arteries in 1º trimester

Normal impedance to flow the uterine arteries in early 2ºtrimester

Normal impedance to flow the uterine arteries in late 2º and 3º trimester

Utero placental circulation

Uterine arteryUterine artery At 24 weeks

No Dichrotic Notch PI < 1.2

At 24 weeks No Dichrotic Notch PI < 1.2

Routine Screening Pre eclampsia & it’s severity can be predicted Monitoring of fetus

Routine Screening Pre eclampsia & it’s severity can be predicted Monitoring of fetus

Uterine ArteryUterine Artery

Uteroplacental circulation

Normal Abnormal

UMBILICAL ARTERIESUMBILICAL ARTERIES

REFLECTS : PLACENTAL OBLITERATION

END POINTS :

ABSENT END DIASTOLIC FLOW

REVERSED END DIASTOLIC FLOW

REFLECTS : PLACENTAL OBLITERATION

END POINTS :

ABSENT END DIASTOLIC FLOW

REVERSED END DIASTOLIC FLOW

NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREGNANCY

NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREGNANCY

Progressive rise in the end-diastolic velocity

Decrease in the pulsatility index.

Progressive rise in the end-diastolic velocity

Decrease in the pulsatility index.

Advancing gestation

UMBILICAL ARTERY

Umbilical artery FlowUmbilical artery Flow

Whether at fetal end, placental end or in between – no difference

Whether at fetal end, placental end or in between – no difference

S/D ratio 2-3 in 2nd & 3rd trimester PI 1.5 – 2.0 in 2nd trimester1.0 – 1.5 in 3rd trimester

RIdecreases with gest. In late 2nd and 3rd it is around 0.5

Umbilical Artery flow What does it tell us ??

Umbilical Artery flow What does it tell us ??

First sign of hypoxia & growth retardationFirst sign of hypoxia & growth retardation

Utero-placental circulation

Utero-placental circulation

Umbilical arteryprogressive

maturation of the placenta and increase in the number of tertiary stem villi.

Umbilical arteryprogressive

maturation of the placenta and increase in the number of tertiary stem villi.

Changes in umbilical artery waveform are evident only when 60% of Placental blood flow is obliterated

Changes in umbilical artery waveform are evident only when 60% of Placental blood flow is obliterated

Umbilical ArteryUmbilical Artery

Normal Umbilical ArteryNormal Umbilical Artery

1º trimester Absent Diastolic Flow

early 2ºtrimester Low Diastolic Flow

late 2º and 3º trimester Resistance further reduce, more diastolic flow

Umbilical Artery - AbnormalUmbilical Artery - Abnormal

Umbilical arteries- normal

Umbilical arteries- high pulsatility index

Umbilical arteries- Absent end diastolic velocity- very high pulsatility index.- pulsation in the umbilical vein

Umbilical arteriesreversal of end diastolic

Umbilical ArteryUmbilical ArteryNormal Abnormal

Utero placental circulation

Umbilical ArteryUmbilical Artery Cordocentesis was carried out in 39 IUGR fetuses Cordocentesis was carried out in 39 IUGR fetuses

Nicolaides

80% Hypoxic46% Acidemic

Absent / Reverse Diastolic Flow

12% Hypoxic00% Acidemic

Positive Diastolic Flow

Umbilical ArteryUmbilical Artery

Clinical significance of absent or reversed end diastolic velocity waveforms in umbilical artery. Lancet 1994;344:1664–8

10.667Reverse End Diastolic flow

4178Absent End Diastolic Flow

1214Positive End Diastolic Flow

Relative Risk of Mortality

No of fetus

Flow in Umbilical

Artery

N = 459

Absent / Reverse End Diastolic FlowAbsent / Reverse End Diastolic Flow Risk to Neonate

More admissions to NICU Increase ICH Increase Anemia Increase Hypoglycemia Increase long term permanent neurological damage

Risk to Neonate More admissions to NICU Increase ICH Increase Anemia Increase Hypoglycemia Increase long term permanent neurological damage

High Resistance Reversal of Diastole

Umbilical artery & CTGUmbilical artery & CTG

Umbilical artery 90% more sensitive to CTG

Interval between absence of end diastolic flow & onset of late deceleration was 3-12 days

Umbilical artery 90% more sensitive to CTG

Interval between absence of end diastolic flow & onset of late deceleration was 3-12 days

Bekedam DJ et al. Early Hum Dev 1990;24:79–89 High Resistance

MIDDLE CEREBRAL ARTERIESMIDDLE CEREBRAL ARTERIES

REFLECTS : CEREBRAL FLOW

END POINTS : RISING PI AFTER A NADIR

REFLECTS : CEREBRAL FLOW

END POINTS : RISING PI AFTER A NADIR

SITESITE

NORMAL & ABNORMAL WAVEFORMNORMAL & ABNORMAL WAVEFORM

The blood velocity increases, PI decreases with advancing gestation

Middle cerebral artery

Middle cerebral artery Decompensation

Brain sparing effect may be transient

Overstressed fetus can lose the brain sparing effect.

Disappearance of brain sparing effect - very critical event for the fetus- precedes fetal death.

MCA may have tremendous implication for determining the proper timing of delivery.

DESCENDING ABDOMINAL AORTA DESCENDING ABDOMINAL AORTA

REFLECTS : FLOW TO THE

ABDOMINAL VISCERA AND

LOWER LIMBS

END POINTS : PULSATILITY INDEX>6

REFLECTS : FLOW TO THE

ABDOMINAL VISCERA AND

LOWER LIMBS

END POINTS : PULSATILITY INDEX>6

SITESITE

NORMAL WAVEFORMNORMAL WAVEFORM

Reflects cardiac output& per. Resistance. Diastolic velocities present during 2nd &3rd

trimesters , PI remains constant. Summation of blood flows to flow in kidneys,

abdominal organs, lower limbs and placenta. Approximately 50% of flow >>umb.artery.

Reflects cardiac output& per. Resistance. Diastolic velocities present during 2nd &3rd

trimesters , PI remains constant. Summation of blood flows to flow in kidneys,

abdominal organs, lower limbs and placenta. Approximately 50% of flow >>umb.artery.

FETAL AORTA

RVLV

Cardiac Function ?Cardiac Function ?

RightVentricle

Left Atrium

Aorta

PulmonaryValve

Pulmonaryartery

Left CoronaryArtery

Right CoronaryArtery

Gembruch & Baschat. Ultrasound Obstet Gynecol 1996;7:10-15

3 D STIC AND INVERSION MODE ANALYSIS

Can a fetus have a heart attack ?

Can a fetus have a heart attack ?

FETAL ILLNESS AND USGFETAL ILLNESS AND USG

PATHOLOGICAL DECREASE IN RATE OF GROWTH (ULTRASOUND B MODE)

SOONER OR LATER GROWTH RESTRICTED FETUSES BECOME HYPOXEMIC,HYPOXIC AND ACIDOTIC (THIS CAN BE DIAGNOSED BY DOPPLER)

FETAL ILLNESS IS RELATED TO FETAL,MATERNAL AND PLACENTAL CAUSES

MOST FREQUENT ETIOLOGY OF A SICK FETUS IS MILD TO MODERATE UTEROPLACENTAL INSUFF DUE TO P.I.H.

PATHOLOGICAL DECREASE IN RATE OF GROWTH (ULTRASOUND B MODE)

SOONER OR LATER GROWTH RESTRICTED FETUSES BECOME HYPOXEMIC,HYPOXIC AND ACIDOTIC (THIS CAN BE DIAGNOSED BY DOPPLER)

FETAL ILLNESS IS RELATED TO FETAL,MATERNAL AND PLACENTAL CAUSES

MOST FREQUENT ETIOLOGY OF A SICK FETUS IS MILD TO MODERATE UTEROPLACENTAL INSUFF DUE TO P.I.H.

Markers For Fetal illnessMarkers For Fetal illness

AFI Chronic Marker NST FT Acute Markers FM FBM

AFI Chronic Marker NST FT Acute Markers FM FBM

Manning’s Biophysical Profile Manning’s Biophysical Profile

NST FBM FM FT AFI Maximum score 10 Minimum 0 Oligohydramnios indicates abnormal BPP

regardless of the total score of others

NST FBM FM FT AFI Maximum score 10 Minimum 0 Oligohydramnios indicates abnormal BPP

regardless of the total score of others

Oligohydramnios IndicatesOligohydramnios Indicates

Abnormal BPP independent of other variables because of a risk of cord complications and fetal death.

Abnormal BPP independent of other variables because of a risk of cord complications and fetal death.

Modified Biophysical Profile (MBPP)Modified Biophysical Profile (MBPP)

® VAST with NST for index of acute hypoxia ® AF Volume – index for chronic fetal problems ® Excellent negative & positive predictive values (Vintzielos) ® Can be performed in 20 mins.

® VAST with NST for index of acute hypoxia ® AF Volume – index for chronic fetal problems ® Excellent negative & positive predictive values (Vintzielos) ® Can be performed in 20 mins.

FETAL BPP VS DOPPLERFETAL BPP VS DOPPLER

AMNIOTIC FLUID IS DUE TO PLACENTAL FUNCTION ,FETAL URINATION,FETAL SKIN,UMBILICAL CORD AND THE BLOOD VOLUME.

AT EARLY PLACENTAL HYPOFUNCTION THE AFI REMAINS NORMAL,NOR IS THE AFI REDUCED IN ACUTE HYPOXIA

THIS PHASE OF F.G.R IS DECEPTIVE TO BPP AND IT IS THIS WHICH IS PICKED UP BY DOPPLER B’COS BY THIS TIME DOPPLER WILL SHOW AEDF OR REDF AND ABNORMAL VENOUS FLOW

HENCE WAITING FOR LESS LIQ WILL DELAY THE MANAGEMENT OF A ILL FETUS

AMNIOTIC FLUID IS DUE TO PLACENTAL FUNCTION ,FETAL URINATION,FETAL SKIN,UMBILICAL CORD AND THE BLOOD VOLUME.

AT EARLY PLACENTAL HYPOFUNCTION THE AFI REMAINS NORMAL,NOR IS THE AFI REDUCED IN ACUTE HYPOXIA

THIS PHASE OF F.G.R IS DECEPTIVE TO BPP AND IT IS THIS WHICH IS PICKED UP BY DOPPLER B’COS BY THIS TIME DOPPLER WILL SHOW AEDF OR REDF AND ABNORMAL VENOUS FLOW

HENCE WAITING FOR LESS LIQ WILL DELAY THE MANAGEMENT OF A ILL FETUS

Hypoxia & MarkersHypoxia & Markers

Umb. pH at which abnormal Test

7.20 Abnormal NST

<7.20 FBM

7.10 - 7.20 Movements

< 7.10 Tone

This should be kept in mind for interpretation of Hypoxia and acidosis

Umb. pH at which abnormal Test

7.20 Abnormal NST

<7.20 FBM

7.10 - 7.20 Movements

< 7.10 Tone

This should be kept in mind for interpretation of Hypoxia and acidosis

Time to deliverTime to deliver

Factors to decide time to deliver Degree of Prematurity NICU facility Degree of Hypoxia, acidemia, hepatic metabolic

derangement

Challenge to weigh the risks and benefits of interventions

Factors to decide time to deliver Degree of Prematurity NICU facility Degree of Hypoxia, acidemia, hepatic metabolic

derangement

Challenge to weigh the risks and benefits of interventions

Time to deliverTime to deliver

When you want to deliver? ? Mild to moderate Hypoxia ? Moderate Hypoxia with early acidemia ?? Severe hypoxia with moderate to severe acidemia

& hepatic metabolic derangements

When you want to deliver? ? Mild to moderate Hypoxia ? Moderate Hypoxia with early acidemia ?? Severe hypoxia with moderate to severe acidemia

& hepatic metabolic derangements

Best time when fetal redistribution mechanism start failing

Take Home MessageTake Home Message

Doppler is very sensitive to detect fetal hypoxia & acedimia

Serial doppler study is required to decide time of delivery to reduce the perinatal morbidity & mortality

Doppler is very sensitive to detect fetal hypoxia & acedimia

Serial doppler study is required to decide time of delivery to reduce the perinatal morbidity & mortality

If Doppler is available

It may identify a fetus with IUGR who registers later and you are uncertain of the gestational age

If Doppler is available

It may identify a fetus with IUGR who registers later and you are uncertain of the gestational age

Low-Risk

SuggestionsSuggestions

Doppler French Study GroupBr J Obstet Gynecol 1997, 104:419

THANK YOUTHANK YOU

FETAL VENOUS CIRCULATION

FETAL VENOUS CIRCULATION

FORAMEN OVALEFORAMEN OVALE

DUCTUS VENOSUSDUCTUS VENOSUS

INFERIOR VENA CAVAINFERIOR VENA CAVA

UMBILICAL VEINUMBILICAL VEIN

RIGHT HEPATIC VEINRIGHT HEPATIC VEIN

MIDDLE HEPATIC VEINMIDDLE HEPATIC VEIN LEFT HEPATIC VEINLEFT HEPATIC VEIN

PORTAL VEINPORTAL VEIN

DUCTUS VENOSUSDUCTUS VENOSUS

REFLECTS : ACIDOSIS

END POINTS : ABSENT FORWARD

FLOW

IN DIASTOLE

REFLECTS : ACIDOSIS

END POINTS : ABSENT FORWARD

FLOW

IN DIASTOLE

SITE DUCTUS VENOSUSSITE DUCTUS VENOSUS

AnatomyAnatomy

Ductus Venosus Flow WaveformDuctus Venosus Flow Waveform

Hecher, Circulation, 1995

Ductus Venosus Flow Ductus Venosus Flow

Modulated by: DV diameter Portal venous resistance Increased Hct increased DV shunt. Humoral factors:

PGs NO Adrenergic stimulus

Modulated by: DV diameter Portal venous resistance Increased Hct increased DV shunt. Humoral factors:

PGs NO Adrenergic stimulus

NORMAL & ABNORMAL WAVEFORMNORMAL & ABNORMAL WAVEFORM

UMBILICAL VEINUMBILICAL VEIN

REFLECTS : MYOCARDIAL FUNCTION

END POINTS : DOUBLE PULSATILE PATTERN

REFLECTS : MYOCARDIAL FUNCTION

END POINTS : DOUBLE PULSATILE PATTERN

SITESITE

ABNORMAL WAVEFORMABNORMAL WAVEFORM

DECOMPENSATIONDECOMPENSATION

FetusFetus Hypoxic fetus

Hypoxic Hypoxia PIH Post maturity Severe Maternal Anemia Sickle cell anemia

Anemic Hypoxia Immune Hydrops Non Immune Hydrops

Ischemic Hypoxia (Acute) Cord Compression Accidental Hemorrhage

Fetus of Diabetic Mother

Hypoxic fetus Hypoxic Hypoxia

PIH Post maturity Severe Maternal Anemia Sickle cell anemia

Anemic Hypoxia Immune Hydrops Non Immune Hydrops

Ischemic Hypoxia (Acute) Cord Compression Accidental Hemorrhage

Fetus of Diabetic Mother

Additional ultrasound findings in identifying IUGR

Additional ultrasound findings in identifying IUGR

• Doppler flow profiles– elevated umbilical artery S/D ratio– elevated uterine artery S/D ratio– persistent diastolic notching in the uterine

artery– decreased middle cerebral artery S/D ratio

Redistribution During Fetal HypoxemiaRedistribution During Fetal Hypoxemia

UMBILICAL ARTERY-High resistance

REDF-PRETERMINAL EVENT

AEDF

Decompensation- aortic isthmus Decompensation- aortic isthmus

When the net flow in the AI becomes retrograde-Nutrient and O2 content of the LV drops -- increased risk for adverse childhood neurodevelopment in fetuses .

When the net flow in the AI becomes retrograde-Nutrient and O2 content of the LV drops -- increased risk for adverse childhood neurodevelopment in fetuses .

AEDF-Per. Vasoconst.-redistribution to MCA.

Acidemia.

Necrotising enterocolitis

AEDF-Per. Vasoconst.-redistribution to MCA.

Acidemia.

Necrotising enterocolitis

FETAL AORTAFETAL AORTA

Retrograde flow in IVC , DV with atrial contraction

UV pulsations

Retrograde flow in IVC , DV with atrial contraction

UV pulsations

CARDIAC FAILURE -VENOUS BLOOD FLOWCARDIAC FAILURE -VENOUS BLOOD FLOW

Staging of growth restricted fetus:Staging of growth restricted fetus:

Intrauterine growth restriction was defined as the presenceof an estimated fetal weight below the 10th percentile. Intrauterine growth-restricted fetuseswere staged according to the following parameters, with the presence of any 1 parameter in a stageplacing the fetus in that stage

Intrauterine growth restriction was defined as the presenceof an estimated fetal weight below the 10th percentile. Intrauterine growth-restricted fetuseswere staged according to the following parameters, with the presence of any 1 parameter in a stageplacing the fetus in that stage

stage Istage I

an abnormal umbilical artery or middle cerebral artery pulsatility index;

an abnormal umbilical artery or middle cerebral artery pulsatility index;

stage IIstage IIan abnormal MCA PSV, absent/reversed diastolic velocityin the UA, UV pulsation and an abnormal DV PI(an absent DV A wave is considered part of thisstage)

stage IIIstage III

reversed flow at the ductus venosus or reversed flow at the umbilical vein, an

abnormal tricuspid E wave (early ventricular filling)/A wave (late ventricular filling) ratio, and tricuspid

regurgitation.

reversed flow at the ductus venosus or reversed flow at the umbilical vein, an

abnormal tricuspid E wave (early ventricular filling)/A wave (late ventricular filling) ratio, and tricuspid

regurgitation.

Each stage divided in A & BEach stage divided in A & B

A is AMNIOTIC FLUID INDEX <5

B is AMNIOTIC FLUID INDEX OF >5

A is AMNIOTIC FLUID INDEX <5

B is AMNIOTIC FLUID INDEX OF >5

The rationale for the division of IUGR fetuses into 3 stages was based on the results of previous studies in which we serially determined the changes of 15 Doppler parameters occurring in IUGR fetuses from the time the diagnosis was made up to delivery.On the basis of results of those studies, we should have divided the set of IUGR fetuses into 15 stages, but to keep the staging as a practical diagnostic tool, we limited it to 3 stages.

The rationale for the division of IUGR fetuses into 3 stages was based on the results of previous studies in which we serially determined the changes of 15 Doppler parameters occurring in IUGR fetuses from the time the diagnosis was made up to delivery.On the basis of results of those studies, we should have divided the set of IUGR fetuses into 15 stages, but to keep the staging as a practical diagnostic tool, we limited it to 3 stages.

Mild utero-placental insufficiency

No effect is seen on Doppler and growth until 26-32 weeks gestation.

The umbilical artery and the middle cerebral artery waveforms may be abnormal

However process is not severe enough to stop fetal growth completely or to deteriorate

These cases may be followed with outpatient monitoring and they often deliver at term.

Mild utero-placental insufficiency

No effect is seen on Doppler and growth until 26-32 weeks gestation.

The umbilical artery and the middle cerebral artery waveforms may be abnormal

However process is not severe enough to stop fetal growth completely or to deteriorate

These cases may be followed with outpatient monitoring and they often deliver at term.

MANAGEMENT STRATEGIES

Assessment of IUGR FetusAssessment of IUGR Fetus

Biometry Fetal assessment for malformation AF Fetal Activity (Biophysical Profile) Color Doppler

Biometry Fetal assessment for malformation AF Fetal Activity (Biophysical Profile) Color Doppler

IUGR Fetal surveillanceIUGR Fetal surveillance

Fetal heart rate monitoring Biophysical profile NST CST VAST Fetal blood sampling Color Doppler Study

Fetal heart rate monitoring Biophysical profile NST CST VAST Fetal blood sampling Color Doppler Study

What Kind of Information on CD ?What Kind of Information on CD ?

Utero placental circulation – Predictive Uterine Artery & Umbilical Artery

Fetal Arterial Circulation – Cut Off Line Redistribution of Blood & brain Sparing Effect

Fetal Venous Circulation - Decision Timing of Delivery Degree of acidemia & Hypoxia

Utero placental circulation – Predictive Uterine Artery & Umbilical Artery

Fetal Arterial Circulation – Cut Off Line Redistribution of Blood & brain Sparing Effect

Fetal Venous Circulation - Decision Timing of Delivery Degree of acidemia & Hypoxia

Changes due to HypoxiaChanges due to Hypoxia

When > 50% placenta is not functioning Mild Hypoxia – Umbilical artery

When > 70% placenta not functioning Moderate Hypoxia -> Compensatory

redistribution in MCA When > 90% placenta not functioning

Severe Hypoxia -> Failure of Compensatory redistribution - DV

When > 50% placenta is not functioning Mild Hypoxia – Umbilical artery

When > 70% placenta not functioning Moderate Hypoxia -> Compensatory

redistribution in MCA When > 90% placenta not functioning

Severe Hypoxia -> Failure of Compensatory redistribution - DV

How to Judge Degree of Hypoxia?How to Judge Degree of Hypoxia?

Fetal arterial doppler

Cut off Line

Fetal arterial doppler

Cut off Line

Fetal arterial circulationFetal arterial circulation Fetal Arterial Circulation – Cut Off Line

Redistribution of Blood & brain Sparing Effect

Fetal Arterial Circulation – Cut Off Line Redistribution of Blood & brain Sparing Effect

MCA – Nadir reached 2 weeks before fetal jeopardy

KidneysGITLimbs, Lungs

BrainMyocardiumFetal adrenal

Less flow of oxygenated blood

More flow of oxygenated blood

Compensatory Redistribution

Pulsatile Umbilical vein Flow

MCA flowMCA flow

PIMore than 1.45 before termFall down to 1If less than 1 peak of redistribution

How to Judge degree of Acidemia?How to Judge degree of Acidemia?

Fetal Venous dopplerFetal Venous doppler

Fetal Venous DopplerFetal Venous Doppler

The PI of the middle cerebral was the best predictors of hypoxemia,

DV flow was the best predictor of Acidemia and hyper capnia.

The PI of the middle cerebral was the best predictors of hypoxemia,

DV flow was the best predictor of Acidemia and hyper capnia.

Rizzo et al. Br J Ob Gyn 1995; 102:963-69

Fetal Venous DopplerIVCDuctus VenosusUmbilical VeinSVC

RA

RV

UVIVC

HVDV

RA

RV

UVIVC

HVDV

Growth Retardation

Umbilical VeinUmbilical Vein

study of 37 fetuses ~~ absent end-diastolic frequencies in the umbilical artery

Neonatal mortality • in group with pulsatile venous flow was 63%, • In group without pulsation was 19%

Arduini D, Rizzo G et al Am J Obstet Gynecol 1993;168: 43–50