color doppler in fetal hypoxia
DESCRIPTION
my presentation at AICOG 2013 WORKSHOP, MUMBAITRANSCRIPT
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