assessment of fetal middle cerebral artery doppler indices...

ميحرلا نمحرلا هللا مسب

The National Ribat University

College of graduate Studies and Scientific Research

Assessment of Fetal Middle Cerebral Artery Doppler

Indices in Normal Pregnancy.

A Thesis Submitted for Partial Fulfillment of the Requirements of M.Sc. Degree in Medical

Diagnostic Ultrasound

By:

Hawa Almasoom Mohammed Zeen Awad Alsed.

Supervisor by:

Dr: Ahmed Abdelrahim Mohammed Ibrahim

2017

I

االيت

لال تعالي :

أَْحَسُن َعَمًلا ۚ َوُهَو الَِّذي َخلََك اْلَمْوَث َواْلَحيَاةَ ِليَْبلَُوُكْم أَيُُّكمْ )

(. اْلعَِزيُز اْلغَفُورُ

صدق هللا العظيم

( 2 االيه رلم)الملك سوره

II

Dedication

I dedicate this work to:-

Those who guide me to such moment my parent

That who gave me happiness my husband.

Those who gave me strength when am weak my brothers and sisters.

III

Acknowledgement

Firstly, great thanks to Allah almighty who made all things possible and

gave me power to do such work.

I would like to extend our heartfelt gratitude to our supervisor Dr. Ahmed

Abdelrahim Mohammed Ibrahim his vital encouragement.

I would like to thank the ultrasound unit staffs of the Department of

Obstetrics and Gynecology of Bahri teaching hospital and Altamayoz hospital

for their kind cooperation and valuable help.

Special thanks to Dr. Zain Elabedeen Mohammad.

IV

Abstract

Doppler sonography of Middle cerebral artery is a useful tool in detecting

fetal complication at risk pregnancies. The aim of this study was to establish a

normative data of the Middle cerebral artery blood flow indices (peak systolic

velocity, resistive index, pulsitility index and systole to diastole ratio) in normal

fetus using ultrasonography .The problem of study is evaluation of normal

Doppler indices of middle cerebral artery in normal Sudanese pregnancy

become very important to reduce perinatal mortality and morbidity in high risk

obstetric cases such as (intrauterine growth restriction, preeclampsia ) and this

study to evaluate normative range of Doppler indices of middle cerebral artery

in fetus. This study was a cross-sectional study, involved 100 women with

singleton normal pregnancy in second and third trimester between 20-40 weeks

of gestation in Department of Obstetrics and Gynecology of Bahri teaching

hospital And Altamayoz hospital from May 2017 to October 2017. Data was

obtained by color Doppler ultrasound system, using Transabdominal

curvilinear transducers with range of frequency ( 3.5 MHz- 5MHz), after fetal

biometry for confirmation of gestational age, Doppler indices measured during

fetal scan, four measurements were taken then the average obtained of S/D

Ratio, RI, PSV and PI recorded in each gestational. The results of Doppler

indices measurements showed that the max and minim values for PSV increased

from 30 to 56.20 ,RI decreased from 0.91 to 0.64, PI decreased from 2.50 to

1.50 and S/D ratio decreased from 7.5 to 5 ,this declined gradually with

gestational age. In conclusion, Doppler indices are more appropriate tools for

assessment of blood flow in Middle cerebral artery; the Middle cerebral artery

Doppler indices showed the decreasing of these indices with increases of

gestational age.

V

ملخص البحث

ْٕ أداة ٔ بٕاسطت انًٕجاث فٕق انصٕحٍت نألٔسدة ٔانششاٌٍٍ نششٌاٌ انذياغً األٔسػحصٌٕش ا

انٓذف يٍ ْزِ . كاٌ ؼانٍت انًخاغشانطبٍؼٍت ٔان فً انكشف ػٍ يعاػفاث انجٍٍُ فً حاالث انحًم يفٍذة

ٔ ٔسػ رسٔة انرشػت االَمباظٍتاأل انذياغًًؤششاث انششٌاٌ يؼٍاسٌت نبٍاَاث إَشاءانذساست ْٕ

هجٍٍُ انطبٍؼً باسخخذاو انًٕجاث فٕق نُبط َٔربت االَمباض نالَبراغ ( ٔيؤشش ان ًمأيتانيؤشش

انًٕجاث فٕق انصٕحٍت بٕاسطت انذياغً األٔسػ نهششٌاٌ انطبٍؼٍتاألسلاو انمٍاسٍت نكً َحذد انصٕحٍت

يؤششاث حذفك انذو باسخخذاو ػًش شانذو، نخمذٌؤشش حذفك ػًش انحًم يغ ي ػ، نشب نألٔسدة ٔانششاٌٍٍ

انذٔنٍت. فً انششٌاٌ انرشي يغ يؤششاث انُخائج حذفك انذونًماسَت يؤششاث انحًم،

هثفً انث جٍٍُ ٔاحذ(طبٍؼً انحًم حانّ يٍ ان 011 ٔلذ ظًج دساست ٔصفٍت يرخؼشظت ْزِ انذساست

انًٕجاث أسبٕػا يٍ انحًم حى انحصٕل ػهٍٓا يٍ لبم َظاو 01-21بٍٍ يٍ فخشِ انحًم انثانث انثاًَ ٔ

نمٍاط تنألجُ انحٌٍٕتانمٍاساث يا أخزثبؼذ(. ضيٍغاٍْشح 3 -5.3 فٕق انصٕحٍت نألٔسدة ٔانششاٌٍٍ

ٔلذ .خالل يرح انجٍٍُ ٍ انًٕجاث فٕق انصٕحٍت نألٔسدة ٔانششاٌٍلٍاساث يؤششاث أخزثانحًم ػًش

ًمأيتانيؤشش حخشاجغ حذسٌجٍا .انًٕجاث فٕق انصٕحٍت لٍاط نًؤشش 011أجشٌج انُخائج نًجًٕع

, 0.31-2.31يغ ػًش انحًم .انمٍى انًخٕسطت اَخفعج يٍ ُبط َٔربت االَمباض نالَبراغ (ٔيؤشش ان

( 34.21 -51رسٔة انرشػت االَمباظٍت يٍ ٔحضداد حذسٌجٍا . ػهى انخٕانً 3 - 5.3 , 1.40 - 1.10

نخمٍٍى حذفك انذو يالئًتأداة أكثشْٕ انًٕجاث فٕق انصٕحٍت نألٔسدة ٔانششاٌٍٍ .خهصج انذساست أٌ

انًٕجاث فٕق انصٕحٍت اَخفاض يؤششاث انذساست باٌ ٔلذ أظٓشث .نذياغً األٔسػافً انششٌاٌ

.انحًمػًش صٌادة يغ األٔسػ انذياغً ًخطػ انششٌاٌننألٔسدة ٔانششاٌٍٍ

VI

List of Contents

Content page No

I اٌَت

Dedication II

Acknowledgement III

Abstract (English) IV

Abstract (Arabic) V

List of contents VI-VII

List of abbreviation VIII

List of figures IX

CHAPTER ONE( Introduction)

1.1.Introduction 1

1.2. The problem of study 3

1.3. general objective 4

1.4. specific objective 4

CHAPTER TWO (Literature review and previous studies)

2. Literature review

2.1. Anatomy of middle cerebral artery 5

2.2. The middle cerebral artery Doppler. 7

2.3. Doppler Parameters. 11

2. 4. Normal flow of the middle cerebral artery 12

2.5. Abnormal flow of the middle cerebral artery. 13

2.6. previous studies 14

CHAPTER THREE (material and methods) 3. material and method 16 3.1.material

3.1.1 Design of study

3.1.2 Place and duration of study

3.1.3 Sample

3.1.4 The population of the study

3.1.5 Machine

3.1.6 Method

3.1.7Method of data collection 17

3.1.8Study variable

3.1.9Method of data analysis

3.1.10Data storage

VII

3.1.11Data presentation

3.1.12Ethical consideration

CHAPTER FOUR( Results) 4. Results 18

CHAPTER FIVE (Discussion, Conclusion and Recommendations) 5.1. Discussion 25

5.2. Conclusion 28

5.3. Recommendations 29

References 30

Appendices

VIII

List of abbreviations

BPD Biparietal diameter.

EDD Expected Delivery Date.

FL Femur length.

GA Gestational Age.

LMP Last menstrual period.

MSA Middle cerebral artery.

PI Pulsitility Index. PSV Peak systolic velocity.

RI Resistive Index. S\D Systole to Diastole ratio.

IX

List of figures

Figure

No.

Figure name Page

No.

2.1 Anatomy of Middle Cerebral Artery. 8

2.2 Early bifurcation of the middle cerebral artery within 1cm of its

origin is a common finding and can be either unilateral or bilateral

8

2.3 There is variability in the division of the middle cerebral artery:

78% bifurcate, 12% trifurcate and 10% have more than three

branches.

8

2.4 measerment Doppler indices of MCA. 13

2.5 Color flow mapping of circle of Willis. 14

2.6 Normal flow of the middle cerebral artery in 1º trimester. 14

2.7 Normal flow of the middle cerebral artery in 2º and 3º trimester. 14

2.8 Fetal adaptation / response to hypoxemia. 15

2.9 IUGR Diagnosis and Evaluation – Longitudinal Study. 15

Chapter one

Introduction

1

1-1 Introduction

Several investigators have studied the fetal cerebral circulation including the

internal carotid, middle cerebral, posterior cerebral, and anterior cerebral

arteries. The middle cerebral artery (MCA) has become the favoured vessel to

study since it is the easiest cerebral vessel to evaluate and has a relatively high

sensitivity in the detection of severe IUGR and related complications. The

normal MCA exhibits continuous forward flow throughout the cardiac cycle

with relatively low end-diastolic flow and consequently having relatively high

PI and RI values. (1)

As the pregnancy advances, the vascular resistance in the MCA decreases and

the Doppler indices change, during the early stages of pregnancy, end-diastolic

flow velocities in cerebral vessels are small or absent, but velocities increase

towards the end of gestation. In the normal developing fetus, the brain is an area

of low vascular impedance and receives continuous forward flow throughout the

cardiac cycle. (2)

Doppler assessment of the middle cerebral artery (MCA) has been shown

effective at evaluating for hypoxia in fetuses that are small for dates. (3)

Anatomically, anteriorlly the circle of Willis is composed of the anterior

cerebral arteries (branches of internal carotid artery connected by anterior

communicating artery); posteriorly, it consists of the two posterior cerebral

arteries (branches of basilar artery connected on either side to ICA), which

supply the cerebral hemispheres on each side. These arteries have different

waveforms, so it is important to know which artery is being interrogated. (4)

2

In study done by M. K. Tarzamni, N. Nezami , F. Gatreh-Samani, et al, under

title Doppler waveform indices of fetal middle cerebral artery in normal 20

to 40 weeks pregnancies. In cross-section study conducted between February

2004 and may 2007 , they analyzed the Doppler measurement of 1037 low-risk

pregnant women with gestational age between 20-40 weeks. The reference

curve of the RI follows a parabolic pattern, increasing from 0.76 at 20 weeks of

gestation to 0.85 at 28 weeks and decreasing to 0.67 at 40 weeks of gestation. A

similar pattern was also observed for the PI (from 1.72 to a maximum of 2.05 at

28weeks to 1.23). And S\D ratio (from 5.34 to a maximum of 7.13 at 30 weeks

to 3.16) . Regarding PSV, an increase of 20 to 54.42cm\s with a peak PSV of

60.85 at 39 week was noted for the observation interval. The was a strong

positive linear correlation between RI and PI (p

3

abetter predictor for fetal outcome in IUGR when compared with umbilical

artery in terms of sensitivity and predictive value.( 6)

In study done by Ebbing et al, under title Middle cerebral artery blood flow

velocities and pulsitility index and the cerebroplacental pulsitility ratio,. A total

of 161 singleton pregnant women include in study Using Doppler ultrasound,

MCA and UA blood velocities and PI were determined three to five times at 3–

5-week intervals over a gestational age range of 19–41 weeks. Polynomial

regression lines for the95th, 50th and 5th percentiles were calculated for the

peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV), and

PI and cerebroplacental ratio. Terms for calculating conditional reference

intervals were established. Results the new longitudinal reference ranges for

fetal middle cerebral PSV, TAMXVand PI provided terms for calculating

conditional reference intervals (i.e. predicting expected 95% confidencelimits

based on a previous measurement), and correspondingly for the

cerebroplacental ratio (n = 550). The reference ranges were at some variance

with those of previous cross-sectional studies. The narrow 95% confidence

limits for the 5th and 95th percentiles ensured reliable ranges. In conclusions

they have established longitudinal reference ranges appropriate for the serial

assessment of MCA blood velocities and PI and cerebroplacental ratio.

Particularly the terms for calculating conditional ranges based on a previous

observation make this system more appropriate for longitudinal monitoring than

are cross-sectional data. (7)

1-2 Problem of study:

Assessment of normal Doppler indices of middle cerebral artery in normal

Sudanese pregnancy become no references range a viable for Sudanese

pregnancy women in normal MCA, and very important to reduce perinatal

mortality and morbidity in high risk obstetric cases such as (intrauterine growth

restriction, preeclampsia) .

4

1-3 Objectives:

13-1 General objective:

To assessed fetal middle cerebral artery Doppler indices in normal pregnancy.

1-3-2 Specific objective:

To measure normal middle cerebral artery Doppler indices ( peak systolic

velocity, resistive index pulsitility index and systole to diastole ratio).

To compare Doppler indices with gestational age.

1-4 Important of study:

It is essential that each institution should have its own baseline data to apply

to the Sudanese population in evaluation of fetal dynamic status. However, the

relationship between gestational age and Doppler waveform indices in

population has not been established. Therefore, will conduct this study to

establish a normative data of the middle cerebral artery Doppler waveform

indices (S/D ratio, PSV, RI and PI) in normal fetuses from gestation age of

(20to 40) weeks.

1-5 Overview of study:

Chapter one: Introduction.

Chapter two: Literature review and previous studies.

Chapter three: Methodology.

Chapter four: Results and analysis.

Chapter five: Discussion, conclusion and recommendations

followed by references and appendices.

Chapter two

Literature review and previous studies

5

2.1 Anatomy of Middle Cerebral Artery

Middle cerebral artery is the largest of the terminal branches of the internal

carotid artery. It lies in the cistern of stem of lateral sulcus/ sylvian fissure

accompanied by superficial middle cerebral vein in the inferior surface of

cerebrum. Then it comes to the lateral sulcus and divides into superior and

inferior division which come to the posterior ramus of the lateral sulcus of the

cerebrum The proximal middle cerebral artery (M1 segment) give rise to the

perforating Branches (Termed Lenticulo striate arteries) that supplies the

putamen, outer Globus pallidum, posterior limb of internal capsule above the

plane of upper border of Globus Pallidum, the adjacent corpora Radiata and the

body of upper and lateral head of caudate nucleus in the sylvian fissure. The

middle cerebral artery is mostly divides in to superior and inferior division.

Branches are end arteries six groups of central arteries are antero median–

single, postero lateral paired. Middle cerebral artery mostly divides into superior

and inferior division. Cortical branches supplies except the region supplied by

anterior and posterior cerebral artery. Cortical branches are Lateral orbito

frontal artery arises from the anterior surface of the horizontal segment of the

middle cerebral artery runs forwards &laterally supplying lateral orbital and

inferior frontal gyri. ,Anterior temporal branch supplies the anterior part of the

temporal lobe on the convex surface .Ascending frontal artery– ascends on the

anterior part of frontal lobe. Pre central (PreRolandic artery). Central–

Roalandic branch. Anterior parietal artery– post Rolandic branch Posterior

parietal Angular artery Posterior temporal artery– all the cortical branch. Lateral

lateralorbito frontal which supplies the Pre frontal cortex. The pre Rolandic

branch which supplies the middle and posterior parts of superior, middle and

inferior Frontal Gyrus. Frontal eye field area and Brocas area. A Rolandic

branch which supplies the pre central and post central Gyrus except the leg area

and Brocas area. Anterior parietal which distributes to the parietal association

cortex and above the supra marginal Gyrus.(8)

6

fig(2-1)

( Anatomy of MCA). (8)

Fig(2-2)

Early bifurcation of the middle cerebral artery within 1cm of its origin is

a common finding and can be either unilateral or bilateral(8)

.

fig(2-4)

There is variability in the division of the middle cerebral artery: 78%

bifurcate, 12% trifurcate and 10% have more than three branches. (8)

7

2.2Middle cerebral artery Doppler

Doppler ultrasound is currently employed in almost every medical discipline to

Study blood flow in diseases where an alteration of this dynamic system is

anticipated. In 1983, Campbell published the assessment of the utero-placental

circulation and that high resistance waveforms were obtained in pre-eclampsia .

The MCA is the vessel of choice to assess the fetal cerebral circulation because

it is easy to identify. When the fetus is hypoxic, the cerebral arteries tend to

become dilated in order to preserve the blood flow to the brain. In the MCA, the

systolic to diastolic (A/B) ratio will decrease (due to an increase in diastolic

flow) in the presence of chronic hypoxic insult to the fetus. This increase in

blood flow can be evidenced by Doppler USG of the MCA. This effect has been

called "brain sparing effect" and is demonstrated by a lower value of the

pulsatility index . In fetuses with intrauterine growth retardation (IUGR) a PI

normal range indicates a greater risk of adverse perinatal outcome. The brain

sparing effect may be temporary, as reported during prolonged hypoxemia in

animal experiments, and the overstressed human fetus can also lose the brain

sparing effect. The disappearance of the brain sparing effect is a critical event

for the fetus, and appears to precede fetal death. Simanaviciute and

Gudmundsson said that normal MCA/uterine artery (UA) PI ratio decreases

with gestational age. Abnormally low MCA/ uterine artery PI ratios are related

to unfavorable pregnancy outcome. Cheema, et al16 observed that a clear

correlation exists between increasing placental vascular impedance and brain

sparing in the MCA. Preterm pregnancies express the greatest deviation from

the mean MCA-PI. (8)

Evaluation of the cerebral blood flow in the fetus has become an integrated

part of the assessment of high risk pregnancies. The middle cerebral artery

(MCA) has been studied extensively, and its Doppler recordings are

incorporated regularly into the management of fetuses at risk of developing

placental compromise and fetal anemia. In cases of intrauterine growth

8

restriction (IUGR), clinical management is based primarily on the waveform

analysis, i.e. the pulsatility index (PI), a low PI reflecting redistribution of

cardiac output to the brain. MCA peak systolic velocity (PSV) is used mainly

for the prediction and management of fetal anemia. However, high MCA-PSV

has been shown to predict perinatal mortality better than does low MCA-PI in a

group of IUGR fetuses6. The surveillance of fetuses at risk usually requires

serial Doppler measurements, including that of the MCA. The use of such

parameters depends on appropriate reference ranges. However, while several

cross-sectional reference ranges are now in use, these are less suitable for serial

observations because the appropriate reference ranges for serial measurements

require longitudinal data. A few longitudinal studies have been published, but

they suffer from too few participants, or lack ranges for commonly used

parameters, and none has developed conditional terms for repeat

measurements.(9)

During the past two decades many fetal vessels and morphologic findings have

been evaluated for ultrasound or Doppler findings that would allow a specific

diagnosis of severe fetal anemia prior to the development of hydrops fetalis. An

excellent review of this experience is available. The optimal time for diagnosis

of severe anemia is prior to the development of hydrops fetalis because the

mortality increases once hydrops has occurred. A group of investigators

working consistently during the decade of the 1990 has now identified that the

fetal middle cerebral artery peak systolic velocity (MCA-PSV) reliably predicts

fetal anemia and can be performed by sonographers consistently with technical

accuracy. The viscosity of blood is inversely correlated with the speed of blood

flow in vessels. Assuming the same pumping force is applied, the lower the

viscosity of blood in vessels, the higher the velocity. When fetal anemia

becomes severe, the viscosity of blood is markedly decreased, and this leads to

a markedly increased peak systolic velocity .between 15 and 36 weeks of

gestation .They performed MCA-PSV measurements at the time of initial

9

referral and every two weeks thereafter, including immediately prior to

cordocentesis. Since hemoglobin concentration in fetuses increases with

gestational age, they developed nomograms for hemoglobin concentration from

265fetuses undergoing cordocentesis for other reasons (suspicion of fetal

infection, alloimmune thrombocytopenia, immune thrombocytopenia purpura

and chromosomal anomalies) who did not have anemia. The expected values for

MCA-PSV were based on nomograms produced previously. The results from

cordocentesis showed that 41 of 111 fetuses at risk for anemia did not have

anemia, had mild anemia, had moderate anemia and 31 had severe anemia. Of

the 31 fetuses with severe anemia, had hydrops fetalis. The sensitivity of MCA-

PSV in detecting moderate or severe anemia was 100% (35/35) and the 95%

confidence intervals were 86–100%. Receiver operator characteristic curves for

the MCA-PSV showed that a level of 1.5 multiples of the median (MOM) or

greater allowed a sensitivity of 100% while only producing a false-positive rate

of 12% (4/35). The concluded that, in fetuses at risk of anemia due to RBC

alloimmunization, moderate and severe anemia can be reliably detected by

noninvasive Doppler assessment using the middle cerebral artery peak systolic

velocity. The appropriate technique for obtaining fetal middle cerebral artery

Doppler waveforms, an axial section of the brain, including the thalami and the

sphenoid bone wings, should be obtained and magnified color flow mapping

should be used to identify the circle of Willis and the proximal MCA , the

pulsed-wave Doppler gate should then be placed at the proximal third of the

MCA, close to its origin in the internal carotid artery(the systolic velocity

decreases with distance from the point of origin of this vessel).The angle

between the ultrasound beam and the direction of blood flow should be kept as

close as possible to 0◦,care should be taken to avoid any unnecessary pressure

on the fetal head. at least three and fewer than 10 consecutive waveforms should

be recorded. The highest point of the waveform is considered as the PSV

(cm/s).(10)

10

The PSV can be measured using manual calipers or autotrace . The latter yields

significantly lower medians than does the former, but more closely

approximates published medians used in clinical practice. PI is usually

calculated using autotrace measurement, but manual tracing is also acceptable.

Color flow mapping of circle of Willis, acceptable middle cerebral artery

Doppler shift waveform, note insonation angle near 0◦, appropriate reference

ranges should be used for interpretation, and the measurement technique should

be the same as that used to construct the reference ranges. Fetal hypoxemia is

associated with increased impedance to flow in the umbilical artery (UA) and

decreased impedance in the fetal middle cerebral artery (MCA). Consequently,

Doppler measurement of UA and MCA pulsatility index (PI) plays a central role

in the assessment and monitoring for fetal oxygenation in pregnancies with

impaired placentation. Most studies have investigated the use of UA-PI and

MCA-PI in pregnancies with small-for-gestational-age (SGA) fetuses, with the

aims of firstly, distinguishing between those which are constitutionally small

from those that are growth restricted and therefore at increased risk of perinatal

death and long-term neurological morbidity and secondly, deciding the best

time, place and mode of delivery. Recent evidence suggests that a high UA-PI

and low MCA-PI, regardless of fetal size, is associated independently with

intrapartum fetal compromise, low neonatal blood pH and neonatal unit

admission. MCA-PI, UA-PI and their ratio (cerebroplacental ratio (CPR)may

have an important role to play in third trimester assessment of fetal wellbeing

and screening for fetal hypoxemia. (11)

11

2.3Doppler Parameters:

The commonly used parameters are:

Middle cerebral artery S/D ratio (SDR): systolic velocity / diastolic

velocity

pulsitility index (PI) : (PSV - EDV) / TAV

resistive index (RI) (: (PSV - EDV) / PSV

PSV: peak systolic velocity

EDV: end diastolic velocity

TAV: time averaged velocity

The Doppler indices have been found to decline gradually with gestational age:

PSV mean value decreases from 60.8 to 54.4

S/D ratio mean value decreases from 7.13 to 5.34.

RI mean value decreases from 0.85 to 0.67.

PI main value decreases from 2.05 to 1.23. (12)

fig(2-5)

measerment Doppler indices of MCA(12)

https://radiopaedia.org/articles/missing?article%5Btitle%5D=umbilical-arterial-sd-ratio

12

2-4 Normal flow of the middle cerebral artery:

Fig (2-5) Color flow mapping of circle of Willis . (8)

Fig (2-6) Normal flow of the middle cerebral artery in 1º trimester. (8)

Fig (2-7)Normal flow of the middle cerebral artery in 2º and 3º trimester.

(13)

13

2-5Abnormal flow of the middle cerebral artery:

Fig (2-8) MCA : Fetal adaptation / response to hypoxemia. (9)

Fig (2-9)IUGR Diagnosis and Evaluation – Longitudinal Study. (9)

14

2-6 previous studies:

In study done by M. K. Tarzamni, N. Nezami , F. Gatreh-Samani, et al, under

title Doppler waveform indices of fetal middle cerebral artery in normal 20

to 40 weeks pregnancies. In cross-section study conducted between February

2004 and may 2007, they analyzed the Doppler measurement of 1037 low-risk

pregnant women with gestational age between 20-40 weeks. The reference

curve of the RI follows a parabolic pattern, increasing from 0.76 at 20 weeks of

gestation to 0.85 at 28 weeks and decreasing to 0.67 at 40 weeks of gestation.

A similar pattern was also observed for the PI (from 1.72 to a maximum of 2.05

at 28weeks to 1.23). and S\D ratio (from 5.34 to a maximum of 7.13 at 30

weeks to 3.16) . Regarding PSV, an increase of 20 to 54.42cm\s with a peak

PSV of 60.85 at 39 week was noted for the observation interval. The was a

strong positive linear correlation between RI and PI (p

15

(P

Chapter Three

Materials and methods

16

3-The materials and methods

3-1The materials:

3-1-1Design of study

This was cross-sectional study done to assess MCA Doppler indicies in

normal pregnancies .

3-1-2Place and duration of study

The Study conducted in Department of Obstetrics and Gynecology of Bahri

teaching hospital And Altamayoz hospital from May 2017 to October 2017 .

3-1-3 Sample

Asymptomatic hundreds of the normal pregnant women attended diagnostic

ultrasound department. They were in gestational age range of (20-40) weeks.

3-1.-4Population of study

Inclusion criteria

Consisting of normal singleton pregnancy and known definite gestational age.

Exclusion criteria

The pregnancy with fetal anomalies, twin’s pregnancy, underlying chronic

disease and abnormal fetal growth.

3-1-5 Machine

general electric (GE) Mindary DC-6diagnostic ultrasound system with rang

of frequency (3.5 MHz- 5 MHz ) curvilinear probe and Alpinion E-CUBE 7

device used for middle cerebral artery.

3-2 Methods:

3-2-1Technique

Middle cerebral arterial Doppler flow is obtained by color Doppler duplex

ultrasound system, using Trans abdominal curvilinear transducers with rang of

frequency (3.5 MHz- 5 MHz), after fetal biometry for confirmation of

17

gestational age, Doppler indices will measure during fetal scan by the same

examiner. The MCA is best visualized with CD in an axial view of the fetal

head just caudal to the plane of the BPD. Either the near or far side MCA can be

sampled. The sample volume should be placed in the MCA near its origin in the

circle of Willis.

3-2-2Method of data collection

The data collected randomly by data collection sheet specially design for this

study.

3-2-3Study variables

Gestational age, peak systolic velocity, resistive index, pulsitility index and

S/D ratio.

3-2-4Method of data analysis

Data analyzed using SPSS program.

3-2-5Data storage

All data collected during the study stored on CD personal computer data

collection sheets and ultrasound images.

3-2-6Data presentation

The data was presented in tables, figures and graphs.

3-3Ethical consideration

Participants informed about the plan of dissemination and publication of

research findings, also they assured that data released only after elimination of

all identifications, and verbal consent obtained.

Chapter four

Results and analysis

18

Chapter Four

Results

Table (4.1) shows descriptive statistic for GA\ BPD, GA FL, AVG GA and PSV, RI, PI,

S\D ratio.

Variables N Minimum Maximum Mean Std. Deviation

GA \BPD 100 20 40 33.79 4.425

GA\ FL 100 20 40 33.79 4.425

AVG\ GA 100 20 40 33.79 4.425

PSV 100 30.00 56.20 40.2766 36.83433

RI 100 .64 .91 .6559 .50082

PI 100 1.50 2.50 1.8965 1.22123

S\D ratio 100 5.00 7.50 6.0058 4.04038

19

Figure (4.1): a scatter plot diagram represent no linear relationship between the RI, PI (Y

axis) and GA-BPD (X axis) in normal pregnancies. The RI and PI decreased by 0.010 and

0.025 respectively as gestational age increased.

Figure (4.2): a scatter plot diagram represent no linear relationship between the PSV and S\D

ratio (Y axis) and GA-BPD (X axis) in normal pregnancies. PSV and S\D ratio decreased by

0.018 and 0.115 respectively as gestational age increased.

RI= -0.010x + 1.003 R² = 0.204

PI= -0.025x + 1.741 R² = 0.25

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

0 10 20 30 40 50

RI &

PI

GA BPD

PSV= -0.018x + 21.88 R² = 0.000

S\D ratio = -0.115x + 6.914 R² = 0.242

0

10

20

30

40

50

60

0 10 20 30 40 50

PSV

\SD

rat

io

GA BPD

20

Figure 4.3: a scatter plot diagram represent no linear relationship between the RI, and PI (Y

axis) and GA-FL (X axis) in normal pregnancies. The RI and PI decreased by0.010and 0.025

respectively as gestational age increased.

Figure (4.4): a scatter plot diagram represent no linear relationship between the PSV and S\D

ratio (Y axis) and GA-FL (X axis) in normal pregnancies. The PSV and S\D decreased

by0.018and 0.115 respectively as gestational age increased.

RI = -0.010x + 1.003 R² = 0.204

PI= -0.025x + 1.741 R² = 0.25

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

0 10 20 30 40 50

RI &

PI

GA FL

PSV = -0.018x + 21.88 R² = 0.000

S\D ratio = -0.115x + 6.914 R² = 0.242

0

10

20

30

40

50

60

0 10 20 30 40 50

PSV

\SD

rat

io

GA FL

21

Figure (4.5): a scatter plot diagram represent no linear relationship between the RI, and PI (Y

axis) and GA-AVG (X axis) in normal pregnancies. The RI and S\D ratio decreased by0.010

and 0.025 respectively as gestational age increased.

Figure (4.6): a scatter plot diagram represent no linear relationship between the PSV and

S\D ratio (Y axis) and GA-AVG (X axis) in normal pregnancies. The PSV and S\D ratio

decreased by 0.018 and 0.115 respectively as gestational age increase

RI = -0.010x + 1.003 R² = 0.204

PI = -0.025x + 1.7412 R² = 0.25

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

0 10 20 30 40 50

RI &

pi r

atio

GA\ AVG

PSV = -0.018x + 21.88 R² = 0.000

S\D ratio = -0.115x + 6.914 R² = 0.242

0

10

20

30

40

50

60

0 10 20 30 40 50

PSV

an

d S

D r

atio

GA\ AVG

22

Table (4.2) correlation between GA \BPD, FL, AVG and PSV, RI, PI and S\D ratio

GA BPD GA FL AVG GA PSV RI PI S\D ratio

GABPD Pearson Correlation 1 1.000** 1.000

** -.012 -.452

** -.500

** -.492

**

Sig. (2-tailed) .000 .000 .909 .000 .000 .000

N 100 100 100 100 100 100 100

GA FL Pearson Correlation 1.000** 1 1.000

** -.012 -.452

** -.500

** -.492

**

Sig. (2-tailed) .000 .000 .909 .000 .000 .000

N 100 100 100 100 100 100 100

AVG Pearson Correlation 1.000** 1.000

** 1 -.012 -.452

** -.500

** -.492

**

Sig. (2-tailed) .000 .000 .909 .000 .000 .000

N 100 100 100 100 100 100 100

PSV Pearson Correlation -.012 -.012 -.012 1 .484** .335

** .374

**

Sig. (2-tailed) .909 .909 .909 .000 .001 .000

N 100 100 100 100 100 100 100

RI Pearson Correlation -.452** -.452

** -.452

** .484

** 1 .665

** .659

**

Sig. (2-tailed) .000 .000 .000 .000 .000 .000

N 100 100 100 100 100 100 100

PI Pearson Correlation -.500** -.500

** -.500

** .335

** .665

** 1 .645

**

Sig. (2-tailed) .000 .000 .000 .001 .000 .000

N 100 100 100 100 100 100 100

S\D ratio Pearson Correlation -.492** -.492

** -.492

** .374

** .659

** .645

** 1

Sig. (2-tailed) .000 .000 .000 .000 .000 .000

N 100 100 100 100 100 100 100

**. Correlation is significant at the 0.01 level (2-tailed).

23

Table (4.3) compare means between GA\ AVG and PSV, RI, PI and S\D ratio .

AVG \ GA PSV RI PI S\D ratio

21 Mean 30.7000 .9700 2.5000 7.6700

Std. Deviation . . . .

23 Mean 36.8500 .7750 2.4500 7.5850

Std. Deviation 31.2020 .10607 .01071 .12021

24 Mean 35.0000 .7700 2.2000 7.0000

Std. Deviation . . . .

25 Mean 30.4750 .9950 2.1000 7.3950

Std. Deviation 20.97607 .05447 .14142 .71468

26 Mean 30.7000 .7700 2.1667 7.7667

Std. Deviation 22.55395 .12124 .28868 .73711

28 Mean 40.0000 .7950 1.9850 7.4650

Std. Deviation 30.82843 .00707 .02121 .04950

29 Mean 40.5667 .7333 1.9833 7.3333

Std. Deviation 20.67644 .04163 .37528 .30128

30 Mean 40.8750 .7200 1.9750 7.9750

Std. Deviation 30.52077 .06976 .22174 .86168

31 Mean 40.1400 .7040 1.9980 7.1800

Std. Deviation 30.99349 .07301 .16131 .65345

32 Mean 40.6429 .7471 1.9057 6.8586

Std. Deviation 30.75138 .08240 .14223 .73099

33 Mean 39.5125 .6988 1.9200 6.9087

Std. Deviation 34.03713 .12449 .21883 .75816

34 Mean 40.3750 .6512 1.8700 6.6875

Std. Deviation 30.9617 .03944 .08816 .48237

35 Mean 40.5325 .6975 1.7938 6.5462

Std. Deviation 30.52961 .07421 .12059 .46626

36 Mean 40.5778 .6256 1.3733 6.6578

Std. Deviation 30.34562 .02744 .10344 .44488

37 Mean 40.7438 .6331 1.4119 6.5562

Std. Deviation 30.71352 .06322 .10451 .42264

38 Mean 55.4875 .6050 1.5937 5.7500

Std. Deviation 31.2538 .11820 .19353 .97724

39 Mean 56.5250 .6562 1.4288 5.4825

Std. Deviation 38.12347 .06632 .15779 .89898

40 Mean 56.4333 .6200 1.5000 5.1000

Std. Deviation 38.48901 .18000 .17321 .36056

Total Mean 40.2766 .6559 1.8965 6.0058

Std. Deviation 36.83433 .10082 .22123 1.04038

24

Table (4.4) Anova table to correlate compare means between GA \AVG and PSV, RI, PI and S\D

ratio

ANOVA Table

Sum of

Squares

df Mean Square F Sig.

PSV &

AVG

Between Groups (Combined) 1547.093 17 91.005 2.425 .004

Within Groups 3077.012 82 37.525

Total 4624.105 99

RI &AVG Between Groups (Combined) .459 17 .027 4.049 .000

Within Groups .547 82 .007

Total 1.006 99

PI &AVG Between Groups (Combined) 2.721 17 .160 6.180 .000

Within Groups 2.124 82 .026

Total 4.845 99

S\D ratio

& AVG

Between Groups (Combined) 52.340 17 3.079 4.606 .000

Within Groups 54.817 82 .669

Total 107.157 99

Chapter five

Discussion, conclusion and

recommendations

25

Chapter five

5.1 Discussion:

This study was carried out to assessment anormative data of the middle

cerebral artery Doppler waveform indices (peak systolic velocity, resistive

index, pulsitility index and systole to diastole ratio) in normal fetus using

ultrasonography. This study includes 100 women with singleton normal

pregnancy in 20-40 weeks of gestation.

Table (4.1) illustrated mean, stander deviation, minimum and maximum of the

variables (gestational age with bi parietal diameter , gestational age with femur

length, and gestational age with average, peak systolic velocity resistive

indices, pulsitility indices and S/D ratio). The higher gestational age was with

biparietal diameter 40 weeks and minimum gestational age was 20 weeks with

mean was 33weeks 6 days ± 4.425. The higher gestational age by femur length

was 40 weeks and the lower gestational age 20 weeks with mean33weeks 6days

± 4.425. The higher gestational age by average gestation was 40 weeks and the

lower gestational age 20 weeks with mean33weeks 6days ± 4.425. The higher

peak systolic velocity was 56.20 and lower peak systolic velocity 30.00 with

mean was40.27 ± 36.83. The higher resistive index was 0.91 and lower resistive

index 0.64 with mean was 6559 ± 0.50082.The higher pulsitility index was 2,50

and lower pulsitility index 1.50 with mean was with1.89 ± 1.22.The higher S/D

ratio was 7.5 and the lower S/D ratio 5with mean was with 6 ± 4.04.

The results of this study showed that there is an inverse linear relationship

between the RI, PI, S\D ratio, and GA-AVG Figure (4.5) the RI decreased by

0.010/week respectively as gestational age increased, this is because of

decreases of the resistance to blood flow in the Middle cerebral arteries falls

with advances of gestation due to continuing development of embryo. The PI

decreased by 0.025 respectively as gestational age increased, this is because of

decreases of the resistance to blood flow in the Middle cerebral arteries falls

26

with advances of gestation due to continuing development of embryo. The S\D

ratio decreased by 0.1157 respectively as gestational age increased, this is

because of decreases of the resistance to blood flow in the Middle cerebral

arteries falls with advances of gestation due to continuing development of

embryo this results agree with previous studies which done by (M. K. Tarzamni,

N. Nezami, F. Gatreh-Samani, et al) there was strong negative linear correlation

between the RI, PI, S\D ratio and gestational age. Because as gestational age

increased the development of embryo continues increased the end diastolic

velocity increased there for, Doppler indices (RI, PI, S/D ratio) decreased.

The results of this study showed that there is a non inverse linear relationship

between the PSV and GA-AVG Figure (4.6): the PSV increased by 0.018/week

as gestational age increased, this is because of decreases of the resistance to

blood flow in the Middle cerebral arteries falls with advances of gestation due

to continuing development of embryo., this results agree with previous studies

which done by (M. K. Tarzamni, N. Nezami, F. Gatreh-Samani, et al) there was

strong positive linear correlation between the PSV and gestational age.

This is study result (PSV 60.85 - 54.42), (RI 0.85 -0.67) (PI 2.05 -1.23), (SD

ratio 7.13-5.34), respectively. Previous study result values of PSV, RI, PI S/D

ratio was (PSV 56.22 - 30.00), (RI 0.91 -0.64) (PI 1.50 -.50), (S\D 7.50 - 5.00

ratio) respectively.

On the other hand evaluation of gestational age results indicates a good

correlation between the three evaluated gestational ages although evaluation

using femoral length it seem to under estimate the gestational age respectively

but still it is within the ±2 weeks limits.

The reference curve of the RI follows a parabolic pattern 0.9 at 20 weeks 0,7at

28,and 0.6 at 40 weeks .A similar pattern was also observed for the PI 2.50 at 20

weeks 2 at 28,and 1.50 at 40 weeks. And S\D 7.5 at 20 weeks 6,7at 28, and 5.00

27

at 40 weeks . Regarding PSV an increase of 20 to 30.42cm\s with a peak PSV

of 56.85 at 39 week was noted for the observation interval

. As well it might be due to the ethnic group because the built in equation has

been developed in a nation possesses different body characteristics than

Sudanese one.

28

5-2 Conclusion:

The main objective of this study was to obtain normative data for Middle

cerebral artery in the second and third trimester pregnancy.

The normal of Middle cerebral artery Doppler waveform indices which

include; PSV, RI, PI and S/D ratio showed a mean value of 40.2766 , 0.65, 1.8

and 6.00 respectively.

The indices values except PSV decreases as results of advances of gestational

age i.e. in respect to fetal development; where resistivity decrease accordingly,

therefore indices should be taken relative to gestational age .

29

5.3 Recommendations:-

1-Assessment of middle cerebral artery blood flow is noninvasive exam should

be used as routine screening test in second and third trimester to improve the

outcome.

2-Doppler ultrasound should be part of setup of every unit that provides

antenatal medial service with good expertise and well trained examiner.

3-Early screening of middle cerebral artery waveform should be performed to

all high risk patient this may help in early diagnosis of preeclampsia and may

decrease the material morbidity and mortality.

4-Further research should also focus on combining between umbilical arteries

Doppler ultrasound with middle cerebral artery; this may improve the

predicative accuracy and the clinical important value of the tests.

Reference

30

References:

1-Johnson P, et al: Middle Cerebral Artery Doppler in Severe Intrauterine

Growth Restriction. Ultrasound Obstetrics and Gynecology , 2001 : P416-420.

2-AsimKurjak MD PHD. Donald school Textbook of ultrasound in Obstetrics

and Gynecology . Third Edition . Jaypee brothers Medical publishers ,Newyork,

2011 :P 507 .

3-Callen P, ed. Ultrasonography In Obstetrics and Gynecology.5th ed.

Philadelphia: Saudners, 2008: P 225–265 and 363–391.

4- Carol MD .Wilson SR. Charbonneau. Levine. Diagnostic ultrasound. 4th ed.

Elsevier Mosby; Philadelphia: 2011. P.708.

5-Wladimiroff JW, Tonge HM, Stewart PA. Doppler ultrasound assessment of

cerebral blood flow in the human fetus. Br J Obstet Gynaecol 1986:p471–5.

6- Kurmanavicius et al, Department of Obstetrics, Zurich University Hospital,

Imperial College School of Medicine, Hammersmith Campus, London, UK

June 2000.

7-Dhand Hemalata, , Kansal Hemant Kumar, Dave Anupama, the Journal of

Obstetrics and Gynecology of India March / April: 2011, p.166 – 171.

8-Ebbing et al, Department of Obstetrics and Gynecology, Haukeland

University Hospital, 2007 ISUOG. John Wiley & Sons, Ltd 2007.

9- Mehmet Çınar et al ,under title Middle Cerebral Artery Doppler Velocimetry

10- Sepulveda W, Shennan AH, Peek MJ. Reverse end diastolic flow in the

middle cerebral artery: an agonal pattern in the human fetus. Am J Obstetrics

and Gynecology 1996:p1645-7.

11- Ultrasound Obstetrics and Gynecology Published online in Wiley Online

Library 2013: p233–239.

31

12- Mari G, Deter RL. Middle cerebral artery flow velocity waveforms in

normal and small-for-gestational-age fetuses. Am J Obstetrics and Gynecology

1992:p1262-70.

13- Fleischer A, Schulman H, Farmakides G et al. Umbilical artery velocity

waveforms and intrauterine growth retardation. Am J Obstetrics and

Gynecology 1985;151:502-5.

Appendices

Appendix (A) Ultrasound images:-

Image No1:Normal MCA artery velocity.spectrial doppler of the MCA in (36week)show

an arterial waveform with forward flow throughout the cardic cycle , dopler indices. PSV= 51

RI=0.72 PI=1.8 S/D ratio=5.6.


an arterial waveform with forward flow throughout the cardic cycle , dopler indices. PSV 55

= RI=0.82 PI 2.00 S/D ratio=6.2.

35

Image No3:Normal MCA artery velocity.spectrial doppler of the MCA in second

trimester(20week)show an arterial waveform with forward flow throughout the cardic cycle ,

dopler indices. PSV= 41RI=0.65 PI=1.90 S/D ratio=2.5

Image No4:Normal MCA artery velocity.spectrial doppler of the MCA in third


dopler indices,PSV= 53 RI=0.74 PI=1.5 S/D ratio= 4.1.

36



RI=0.8 PI=1.8 S/D ratio6.2


an arterial waveform with forward flow throughout the cardic cycle , dopler indices. PSV=50

RI=0.77 PI=2.8 S/D ratio=4.4

37



RI=0.85 PI=1.2 S/Dratio=6.63



RI=0.70 PI=1.8 S/D ratio=6.5

38



RI=0.70 PI=1.5 S/D ratio=5.3



RI=0.7 PI=1.5 S/Dratio=4.2

39

Appendix No11:Normal MCA artery velocity.spectrial doppler of the MCA in

(32week)show an arterial waveform with forward flow throughout the cardic cycle , dopler

indices. PSV= 47.7 RI=0.86 PI=1.2 S/D ratio=6.9



RI=0.80 PI=1.6 S/Dratio=4

40



RI=0.8 PI=1.6 S/D ratio=6.6


an arterial waveform with forward flow throughout the cardic cycle , dopler indices. PSV =53

RI=0.72 PI=1.8 S/D ratio=5.9

41



dopler indices. PSV= 37 RI=0.74 PI=1.2 S/D ratio=6.3.



dopler indices. PSV=49 RI=0.75 PI=1.80 S/D ratio=6

42



RI=0.73 PI=1.5 S/D ratio=6.7



RI=0.8PI=1.98 S/D ratio6.6.

43






RI=0.74 PI=1.3 S/D ratio=4.8.

44



RI=0.74 PI=0.8 S/D ratio=6.7.



RI=0.72 PI=0.8 S/D ratio=4.3.

45



RI=0.81 PI=0.8 S/D ratio=5.3.



RI=0.77 PI=1.2 S/D ratio=4.

46






RI=0.85 PI=1.7 S/D ratio=4.6.

47

Image No27:Normal MCA artery velocity.spectrial doppler of the MCA in 23week)show


RI=0.85 PI=1.5 S/D ratio=6.6.



RI=0.83 PI=2. S/Dratio=5.6.

48



RI=0.72 PI=1.6 S/D ratio=5.6.



RI=0.62 PI=1.8 S/Dratio=6.6

49

Appendix (A)

National Ribat University

Faculty of graduate Studies

Data Collection Sheet

Assessment of middle cerebral artery Doppler indices in normal pregnancy.

Data Collection Sheet

NO

LMP

GA by

BPD

GA by

FL

Average

of GA

PSV

RI

PI

S\D

EDD

1

2

3

4

5

6

7

8

9

10

assessment of fetal middle cerebral artery doppler indices...

Documents