PROF.NARENDRA MALHOTRAM.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S.,F.M.A.S.,F.I.A.P.

• Prof. Dubrovnick International University

• V.P. WAPM(world association of prenatal medicinne)

• President ISAR

• Presiddent Elect ISPAT

• Sec Gen SAFOG

• Member FIGO guidelines committee

• President FOGSI (2008-2009)

• Dean I.C.M.U. (2008)

• Director Ian Donald School of Ultrasound

• National Tech. Advisor for FOGSI-G.O.I.—Mc Arthur Foundation EOC Course

• Managing Director GLOBAL RAINBOW HEALTH CARE

• Director ART-RAINBOW –IVF

• Practicing Obstetrician Gynecologist at Agra. Special Interest in High Risk Obs., Ultrasound, Laparoscopy

and Infertility, ART & Genetics

• Member and Fellow of many Indian and international organisations

• Awarded best paper and best poster at FOGSI : 5 times, Ethicon fellowship, AOFOG young gyn. award,

Corion award, Man of the year award, Best Citizens of India award

• Over 50 published and 200 presented papers

• Over 100 guest lectures given in India & Abroad and 24 ORATIONS

• Organised many workshops, training programmes, travel seminars and conferences

• Editor 18 books, many chapters, on editorial board of many journals

• Editor of series of STEP by STEP books

• Revising editor for Jeatcoate’s Textbook of Gynaecology 7th and 8th edition (2015)

• Very active Sports man, Rotarian and Social worker

MALHOTRA NURSING & MATERNITY HOME PVT. LTD.

GLOBAL RAINBOW HEALTH CARE,AGRA

84, M.G. Road, Agra-282 010Phone : (O) 0562-2260275/2260276/2260277, (R) 0562-2260279, (M) 98370-33335; Fax : 0562-2265194

www.malhotrahospitals.com,www.rainbow hospitals.org

Color doppler in FGR making sense of the waves

Narendra MalhotraJaideep Malhotra

Neharika Malhotra BoraRishabh Bora

Ashok Khurana,S Suresh,Kuldeep Singhwww.rainbowhospitals.org

mnmhagra3@gmail.com

OBJECTIVES OF THIS TALK

• Describe Doppler technique in different blood vessels

• Discuss Doppler role in FGR fetuses

• Understand the value of Doppler in fetal anemia

• Present Doppler frontiers

COLOR DOPPLER

Principles of Color Doppler

Color flow mapping

Power Doppler

THE DOPPLER EFFECT

Principles of Color Doppler

Quantitative analysis

Doppler indices

3D DOPPLER

UTERO-PLACENTAL CIRCULATION

• PLACENTAL CIRCULATION– progressive maturation of

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

Sadler TW Lagman’s Medical Embryology 1990

Umbilicalvessels Chorionic

vesselsChorionic

plate Amnion

Spiralartery

PlacentalseptumBasal

plateUteroplacental

veins

FETAL CIRCULATIONARTERIAL VENOUSCARDIAC HEMODYNAMICS

CLINICAL APPLICATIONS

• Common applications (FGR)

• Other applications (fetal anemia)

• New applications

• 3D Doppler

DOPPLER IN IUGR

• To identify etiology of FGR

– Placental / non placental

• To identify hypoxia & fetal adaptation

• To plan timing of delivery?

• To identify fetuses at risk of perinatal complications

DOPPLER IN FGR

• To identify vascular bed resistance

– Uterine artery

– Umbilical artery

• To identify fetal adaptation

– MCA

• To identify cardiac decompensation

– Ductus venosus

– Umbilical vein

DOPPLER IN FGR

Doppler meta analysis has shown that the use of the UA

Doppler reduces the number of:• antenatal admissions: 44%

• inductions of labor: 29%

• C/S for NRFS: 52%

• perinatal mortality: 38%

Alfirevic Z, Neilson JP

ACOG 1995;172;1379-87

A DOPPLER REPORT

A REPORT

FETAL HYPOXIA-ACIDOSIS

AORTIC BODY CHEMORECEPTOR STIMULATION

REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT

REFLEX REDISTRIBUTION OF FETAL CARDIAC OUTPUT

INCREASED FLOWDECREASED FLOW

KIDNEYS (OLIGURIA)

(OLIGOAMNIOS)

LUNGS (RDS)

GUT (NEC)

LIVER/MUSCLE (IUGR)

BODY FAT/

GLYCOGEN STORES

BRAIN

ADRENALS

HEART

UMBILICAL ARTERY

• Low impedance circulation

• S/D index (A/B index)

• Placental insertion has least impedance

• Intervene for absent or reversed EDF

UMB ART SIGNIFICANCE

60% tertiary villous artery occlusion

>70% tertiary villous artery

occlusion

Trudinger, Br J Obstet Gynecol, 1985

Abuhamad, COG, 2003

ABNORMAL UMB A WAVEFORMS

DECREASED EDF ABSENT EDF REVERSED EDF

Nicolaides, Placental and Fetal Doppler

Diploma in Fetal Medicine Series, 2000

Absent / Reversed End Diastolic flow is associated with severe IUGR, oligohydramnios,

increased risk of neonatal mortality and morbidity (cerebral hemorrhage, anemia and hypoglycemia).

UA DOPPLER – REVERSED DIASTOLIC FLOW

This is an advanced stage of fetal compromise, associated with increased perinatal morbidity and mortality.

MCA DOPPLER

• Most accessible cerebral vessel

• Carries 80% of cerebral flow

• Excellent reproducibility

MIDDLE CEREBRAL ARTERY “FETAL ADAPTATION”

31 weeks, IUGR, PI=1.22 33 weeks, IUGR, PI=1.11

Decreasing trend in MCA PI suggests further blood flow redistribution to the brain.

MCA DOPPLER

Normal

Abnormal – fetal hypoxia

Alteredcerebroplacental ratio

VENOUS CIRCULATION

Central:• ductus venosus, hepatic veins, IVC

– characteristic pulsations

Peripheral:• portal veins, umbilical vein

– no pulsations

DUCTUS VENOSUS TURBULENCE (DV)

• Reversal of A- wave flow in the DV - sensitivity of 53% for perinatal mortality.

• A-velocity below the 5th percentile in DV - 79%

sensitivity for fetal demise.

A cut-off value for DV PIV of 2–3 SD seems to be most appropriate for delivery. (C. M. BILARDO et al, UOG, 2004)

1st tri 2nd Tri 3rd tri

Normal DV wave forms

VENOUS DOPPLER NORMAL FETUS

IVC Doppler

DV Doppler

HYPOXIC FETUS

IVC Doppler

DV Doppler

OBSTETRIC ULTRASOUNDPROTOCOLS OVER THE YEARS

UTERINE ARTERY DOPPLER FOR PREDICTON OF IUGR

LR ut art dop IUGR

LR

Pre-eclampsia

LR

Perinatal death

LR

ABN 3.7 5 2.4

N 0.7 0.5 0.8

UTERINE CIRCULATION

• Low impedance circulation in pregnancy

• S/D or RI – standard indices

• Low EDF & notching – abnormal findings

• Associated with elevated MS AFP & hCG

UTERINE ARTERY

• Abnormal waveforms:

– FGR

– Pre-eclampsia

– FHR abnormalities

NORMAL & ABNORMAL WAVEFORM IN ADVANCED PREG

Diastolic Notch(irrespective of the RI PI))

FGR

• Challenge:

– Diagnose true IUGR

– Identify markers of morbidity

– Intervene in a timely fashion

Evaluation of FGR

PIH/ HT/ DM/ Renal diseasePrevious FGR / Still birthAPA

Maternal

Fetal

USGto R/O structural abnormalitiesFetal echoInvasive fetal testingKaryotypingFetal infections

TIMELINE FOR FETAL HYPOXIADOPPLER SUMMARY

• Abnormal fetal growth

• Abnormal arterial Doppler (UA, MCA)

~ 2 weeks

• Abnormal venous Doppler (IVC & ductus venosus)

~ 1-2 days??

• Abnormal NST / BPP score

SEQUENTIAL CHANGES IN TESTS OFFETAL WELL BEING

THE ACTION POINTS..

Doppler

Incflow FetalMCAPI< 5th

Umbilical artery HRF PI> 95thplacental resistance

increasing hypoxia

acidosis Venoussystem-Ductusvenosus/umbveinearly/ late

Cerebroplacentalratio

MCA PI/ UA PI <1 or < 5thcentile

Early vs Late onset FGR

Both have poorlongtermneurodevelopmental, cardiovascular, and metabolicparametresBoth are associated with placental disease but may be different types of diseaseGAcutoffis arbitrary and could be 32 weeks

Early onset severe FGR

Mild late onset FGR

In severe maternal disease,

progression is unpredictable

Aim of monitoring

TO INTERVENE IN TIME

Monitor growth Biometry

Detect hypoxia Doppler

PreventacidemiaDoppler/BPP/ CTG

Daily fetal movement count

MONITORING – HOW OFTEN?

Frequency dictated by Severity of growth restriction Gestational age of the fetus

Biometry 2 – 3 weeks No value for biometry if interval is less than 2 weeks

Doppler 2 – 3 weeks if mild weekly / biweekly if severe dysfunction

AFI – weekly / bi weekly

DOPPLER & FETAL ANEMIA

• Anemia:

– Increased cardiac output

– Decreased blood viscosity

– Increased blood velocity

• Peak systolic velocity of MCA

• Why MCA?

– Increased blood flow to brain in anemic fetus

– MCA lends itself to insonation angle close to zero

– Low inter- and intra-observer variability

DOPPLER & FETAL ANEMIA

MCA PSV:

• Moderate to severe anemia:

– Sensitivity 100%

– FPR 12%

Mari C et al. NEJM 2000;342:9

• Parvo virus

– Sensitivity 94.1%

– Specificity 93.3%

ACOG 2002

Aghajanian P et al. Fetal middle cerebral artery Doppler fluctuations after laser surgery for twin-twin transfusion syndrome.

J Perinatol. 2011 May;31(5):368-72. Epub 2010 Dec 9.

• The objective to compare alterations in the MCA PI and mean velocity (V mean) after laser surgery for twin-twin transfusion syndrome (TTTS).

• Despite the changes in the MCA PI after laser for TTTS, the MCA V (mean) remained constant.

• These findings may suggest some autoregulatory capacity in the cerebral vessels of the mid-trimester fetus.

NEW APPLICATIONS

Umbilical artery notching:

• Cord entanglement

• True knot

• Cord stricture

• Velamentous insertion

• Tight nuchal cords

• Abnormal cord coiling

JUM 2002;21:857

PLACENTA - 3D DOPPLER

VASCULARIZATION INDEX (VI)

• VI = measures % of color pixels in ROI that represent flow

FLOW INDEX (FI) & VASCULARIZATION FLOW INDEX (VFI)

• FI = measures intensity of color pixels in ROI

• VFI = combines % of color pixels and intensity in ROI (0-100 normalized)

3-D CALCULATIONS

J Ultrasound Med 26:1469-1477 • 0278-4297 Staging of Intrauterine Growth-Restricted Fetuses

Giancarlo Mari, MD, Farhan Hanif, MD, Kathrin Drennan, MD and Michael Kruger, MA

• The staging system proposed here may allow comparison of outcome data for IUGR fetuses and may be valuable in determining more timely delivery for these high-risk

fetuses.

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

STAGE I

• an abnormal umbilical artery or middle cerebral artery pulsatility

• index;

STAGE II

an abnormalMCA 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 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.

EACH STAGE DIVIDED IN A & B

• A is AMNIOTIC FLUID INDEX <5

• B is AMNIOTIC FLUID INDEX OF >5

Staging of IntrauterineGrowth-Restricted Fetuses

Giancarlo Mari, MD, Farha n Hanif, MD,Kathrin Drennan, MD, Michael Kruger, MA

• The purpose of this study was 2-fold: (1) to assess the clinical relevance of a staging system for IUGR fetuses that would include ultrasonographic, Doppler, and clinical data; and (2) to

propose a classification that can be used for all types of IUGR fetuses

• The rationale for the division of IUGR fetusesinto 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.

• Stage I fetuses have mild IUGR, and we

can treat these patients as outpatients

• stage II and III patients need to be admitted to

the hospital.

• Stage II patients are admitted for observation,

• stage III patients are at

• high risk for fetal death.

• The major advantage of selecting the parameters included in this staging system is the ability to clearly track the progression of abnormal parameters that start at the UA and MCA and later to progressively extend the evaluation to the other parameters up to the time of fetal death if the fetus remain undelivered.

• Another advantage is the simplicity of the system.

• Only 4 fetal vessels and 1 cardiac valve need

to be investigated with Doppler ultrasonography.

Furthermore, it is not necessary to determine the

parameters reported for a certain stage if the

parameters of the previous stage are normal. For

example, if the UA and MCA PI values are normal,

it is not necessary to determine the parameters

of the next stage

This makes the staging

system easily applicable

• Our data indicate that the staging system proposed

• here is applicable in pregnancies at gestational

• ages of both less than and greater than 30

• weeks, which makes the staging system reliable

• with regard to different gestational ages

• If a fetus has an estimated fetal

• weight below the 10th percentile and both the

• UA PI and the MCA PI are normal, we classify it

• as stage 0.

Time 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

Timing of delivery- TRUFFLE

The objective ofthis studywas to describeperinatal

morbidity andmortalityfollowingearly-

onsetfetalgrowth restriction basedontimeof antenatal diagnosis anddelivery

Outcomes

perinatal death

severe perinatal morbidity

Trial of randomised umbilical andfetalflow in EuropeLees et al, UltrasoundObstetGynecol2013

TRUFFLE

Recruitment of very early FGRs26-32 weeks with EFW < 10thcentile and UA PI > 95thcentile

Delivery based on

ARM1 abnormal CTG/ reduced STV

ARM2 early DVchanges-PI>95thcentile

ARM3late DV changes absent orreverseda wave

TRUFFLE-Implications for

management

< 30 weeks

Management based on DV

Neuro outcome better if

delivery is based on

absent or reversed ‘a’ wave

Or

If CTG STV is abnormal

After 30 weeks, deliver if:

30-32wks-reversed EDF

32-34wks- absent EDF

34-36wks- increased PI

PREGNANCY MANAGEMENT

• Abnormal UA Doppler– Decreased diastolic flow

• Increase frequency of testing; consider deliver >37 weeks

– Absent end diastolic flow• Steroids; consider delivery at 34 weeks

– Reversed end diastolic flow• Steroids: consider delivery at 32 weeks

Am J Obstet Gynecol. 2012 Apr;206(4):300-8.

PREGNANCY MANAGEMENT

• 37 or more: delivery if NRFS; elective delivery after 38-39 weeks

• <34 weeks:– Expectant management if reassuring fetal

status – Rx corticosteroids for fetal benefits

– Modified bed rest, smoking cessation, Rx hypertension

– Antepartum testing: NST/AFI & BPP twice weekly, daily kick counts, UA Doppler

– Abnormal UA Doppler: daily NST and at least twice weekly BPP for up to 2 weeks

– Non-reassuring status: evaluate for delivery

PREGNANCY MANAGEMENT

• 34-37 weeks– Management individualized

– Antepartum testing: NST/AFI twice weekly, UA Doppler

– Non-reassuring status: evaluate for delivery

– Oligohydramnios and abnormal UA Doppler: more frequent antepartum testing but not delivery (unless non-reassuring status)

When to deliver?

<28wksDifficult decisionCounselingChallenge to the neonatologist

When to deliver?

>34weeks

Low threshold for delivery

Abnormal doppler

When to deliver?

32-34weeks

Continue to monitor when high resistance in UA and cerebral redistribution

Absent or reversed EDV is an indication for

immediate delivey

When to deliver?

28-32weeks

Absent or reversal of EDV in venousdoppler(DV)

Abnormal Biophysical profile

Spontaneous decelerations

When to deliver?

<28weeks

Difficult decision

Parents to be extensively counseled

Challenge for the paediatriciansin terms of

prolonged care

Planning mode of delivery

SGAumbilical artery AREDV

Cesareansection

SGAnormal umbilical artery Doppler or with abnormal umbilicalarteryPI butend–diastolic velocitiespresent

Induction can be offered continuousmonitoring

SGA with normaldoppler

Senior input about time / mode

Continuous CTG

BERLIN C0NCENSUS

ROAD TO DEATH

Take home message

SGA is a complex diagnostic exercise and FGR is a significant perinatal problem

Distinction between growth restricted baby and a low growth potential baby is a critical issue

Take home message

Majority occur in low risk pregnancies

Prospective screening of all pregnancies may help in predicting FGR- debatable

Take home message

Commonly due to ischemic placental disease

No therapeutic intervention to reverse the process

Timing of delivery is crucial tooptimiseoutcome

Take home message

Dating of pregnancy is vital

Serial scans may be required

Growth charts

Rule out underlying cause- aneuploidy and

infections in early onset FGR whendopplersare normal

Take home message

Deliver at 34wks/ deterioration

Doppler particularly venousdoppleris the cornerstone of monitoring

Prepare thepaedsand the parents

Intervene before acidosis sets in

CONCLUSIONS• Doppler ultrasound is integral part in management of

IUGR, fetal anemia, placental abnormalities, twins

• 3D Doppler is a unique technique that enables assessment of vascular signals within the whole investigated area.

• Homodynamic changes included in the process of placentation are one of the most exciting topics in the investigation of human development.

WHEN DOPPLER STUDY IS

NORMAL

The diagnosis of IUGR is doubtful

(Brodoszki, et al., 2002)

It may be a constitutionally small normal

fetus (Burket et al, 1990, Pattnson, et al 1994)

Small fetus with normal Doppler left

unmonitored (Baschat and Weiner, 2000)

Expectant management on continued

surveillance (Harman and Baschat, 2003)

If Doppler is

available

It may identify a fetus with IUGR

who registers later and you are

uncertain of the gestational age

Low-Risk

Suggestions

Doppler French Study Group

Br J Obstet Gynecol 1997, 104:419

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