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![Page 1: N ZEALAND OBSTETRIC DOPPLER UIDELINE - asum.com.au · New Zealand Obstetric Doppler Guideline, NZMFMN , revised October 2015, Page 1 NEW ZEALAND OBSTETRIC DOPPLER GUIDELINE This is](https://reader031.vdocument.in/reader031/viewer/2022022117/5cb02a9c88c993c3598be0af/html5/thumbnails/1.jpg)
NewZealandObstetricDopplerGuideline,NZMFMN,revisedOctober2015,Page1
NEWZEALANDOBSTETRICDOPPLERGUIDELINE
ThisisaNewZealandguidelinefortheperformanceofobstetricDopplerexaminations.TheguidelineincorporatesdetailednotesoncorrectDopplertechnique,interpretationandreferencechartsforeachofcommonlyusedobstetricDopplerexaminations.Allhealthpractitionersinvolvedintheperformanceandinterpretationofobstetricultrasoundexaminationsareencouragedtousethisdocumentandincorporatetheprinciplesandreferencevaluesintotheirclinicalpractice.
Unalteredcopiesofthisguidelinemaybefreelyreproducedanddistributed.
Contributors:MartinNecas,DrEmmaParry,ProfessorLesleyMcCowan
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NewZealandObstetricDopplerGuideline,NZMFMN,revisedOctober2015,Page2
WhichDopplerTestWhen?
SGAorIUGR UmbilicalarteryPI +
MeanuterinearteryPIattimeofdiagnossi(once)
UmbilicalarteryPIraised AddMCAPI+CPR Samedayreferraltospecialist
AddMCAPI+CPR Specialistreviewnow
Absentorreversedend-diastolicflow
Normal>34weeks AddMCAPI+CPR
Normal<34weeks Specialistreviewin1-2weeks
AtriskofearlyonsetmaternalhypertensivedisorderorSGA
MeanuterinearteryPIat20or24weeks
Suspectedfetalanaemia MCAPSV
MCDATwins NoevidenceofTTTS Bothtwins: UAPIfrom16weeks+MCAPSVfrom24weeks
Bothtwins: UAPI,MCAPI,MCAPSV,DVPI TTTS
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UmbilicalArteryPulsatilityIndex(UAPI)Indications:
§ Suspectedorknownsmallforgestationalage(SGA)fetus§ TheestimatedfetalweightontheGROWchartis<10thpercentile§ TheestimatedfetalweightontheGROWchartisdroppingpercentilesby≥30%§ Theabdominalcircumferenceonthepopulationscanchartis<5thpercentile§ Discrepancy(≥30%)betweentheheadandabdominalcircumferencepercentilewithlowerACpercentile§ Maternalhypertensivedisorderse.g.preeclampsia§ Decreasedfetalmovements
Notindicated:§ Routinescreeningofnormalpregnancieswithnomaternalorfetalriskfactors
Howtoperformthetest:§ Performassessmentduringfetalquiescence§ AlwayskeepTIb<0.5ifpossibleoratleast<1byreducingtheacousticoutputpower§ IdentifyafreeloopofumbilicalcordoncolourDoppler§ UsehighcolourPRFtoavoidaliasingandconservativegaintoavoidcolourbleeding§ PositionthesamplevolumeinaportionofthecordcoursingparalleltoDopplerbeam§ AvoidsamplinginsuchawaythattheDopplerbeamisdirectedtowardsfetaleyes§ OptimisethespectralDopplerbaseline,PRFandsweepspeedtogetalargewaveform§ IftheEDVisnearthebaseline,ensurewallfilterissufficientlylowtodisplayEDV§ IfthePIiswithinnormalrange,onlysampleoneoftheumbilicalarteries§ IfthePIisabnormal,samplebothumbilicalarteriesandusethemorenormal(lower)value§ Iftheend-diastolicflowisabsentorreversed,commentonthisfindinginthereport
Howtointerpretthetest:§ >95thpercentileisabnormal
Commonpitfalls:§ PoorDopplerangleandpooroptimisationleadingtofuzzywaveformwhichishardtomeasure§ End-diastolicflowisnotvisualisedduetohighfiltersetting§ End-diastoleisnotwellvisualisedwhenEDVisnearbaselinebecauseofvenouscontamination-
readjustsamplingtoavoidcapturingadjacentUV
Reference:Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatilityratio:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.
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MiddleCerebralArteryPulsatilityIndex(MCAPI)Indications:
§ SGAwithabnormalUAPIatanygestationalage§ SGAwithnormalUAPIafter34weeksgestationalage§ MCDAtwingestationwithTTTS
Howtoperformthetest:
§ Performassessmentduringfetalquiescence§ AlwayskeepTIb<0.5ifpossibleoratleast<1byreducingtheacousticoutputpower§ StartwiththeBPDview§ Movecaudallytovisualisethebutterflyshapeofsuprasellarcisternsandthesphenoid§ Usethecoronalsuture/sphenoidalfontanelleasanacousticwindow§ Usehighdefinition(write)zoom§ ActivatecolourDopplertovisualisetheMCA§ AssesstheMCAwhichisclosertothetransducer§ MoveanteriorlyandanglebacktoaligntheMCAflowdirectionwiththeDopplerbeam§ Positionasmall(0.5-1mm)samplevolume2mmbeyondfromtheMCAorigin§ OptimisethespectralDopplerbaselineandPRFtogetalargewaveform
Howtointerpretthetest:
§ <5thpercentileisabnormal
Commonpitfalls:
§ PoorDopplerangleandpooroptimisationleadingtofuzzywaveformwhichishardtomeasure§ GatetooclosetoMCAoriginwheremultidirectionalcontaminationfromACAandPCoAoccurs§ SamplepositionedtooperipherallyintheMCAwherevelocitiesfall§ PCAmisidentifiedasMCA§ Poorvisualisationduetoinadequatezoom
Reference:Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatilityratio:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.
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CerebroplacentalRatio(CPR)Indications:
§ IfMCAPIassessmentwasperformed,theCPRshouldbecalculatedandrecorded
HowtocalculateCPR:
§ TheCPRisdefinedtheratioofMCAPIandUAPI
Howtointerpretthetest:
§ <5thpercentileisabnormal§ Note:ItcanbehelpfultoplottheMCAandCPRresultsonserialassessmentsto
determinethetrend
Reference:Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatilityratio:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.
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DuctusVenosusPulsatilityIndex(DVPI)Indications:
§ MarkedlyraisedUAPI(>>95th)andreducedMCAPIinpretermSGA§ MCDAtwingestationwithTTTSorselectiveIUGR
Howtoperformthetest:
§ Performassessmentduringfetalquiescence§ AlwayskeepTIb<0.5ifpossibleoratleast<1byreducingtheacousticoutputpower§ SagittalandtransverseapproachesareacceptableaslongasDopplerangleis0-60degrees§ ActivatecolourDopplertoidentifyDVattheendofUV§ Enlargetheimage§ 0.5-1mmgateplacedintheinletofDV§ Setwallfilterlow,sweepspeedhigh§ OptimisethespectralDopplerbaselineandPRFtogetalargewaveform§ IfPI>95thpercentile,assessumbilicalveinforpulsatility
Howtointerpretthetest:
§ >95thpercentileisabnormal
CommonPitfalls
§ ColourPRFtoolowandgaintoohighleadingtodifficultyinDVidentificationamongstothervessels§ Samplesizetoolarge,leadingtocontaminationfromothervessels§ SamplenotplacedattheinletoftheDV§ AdjacenthepaticveinorceliacaxismisidentifiedasDV§ PoorDopplerangleandpooroptimisationleadingtofuzzywaveformwhichishardtomeasure§ FetalbreathingactivitymayresultinfalseimpressionofabsentAwave
Reference:Kessler,J.,Rasmussen,S.,Hnson,M.,&Kiserud,T.Longitudinalreferencerangesforductusvenosusflowvelocitiesandwaveformindices.UltrasoundObstetGynecol,2006.28:890-898.
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MCAPeakSystolicVelocity(MCAPSV)Indications:
§ Maternal-fetalisoimmunisation§ Anysuspicionoffetalanaemia§ Unexplainedhydrops§ MCDAtwins>24weeksgestationalage§ MCDAtwinswithknownorsuspectedofTTTSorTAPS
Howtodoperformthetest:
§ Performassessmentduringfetalquiescence§ AlwayskeepTIb<0.5ifpossibleoratleast<1byreducingtheacousticoutputpowerwhenrequired§ StartwiththeBPDview§ Movecaudallytovisualisethebutterflyshapeofsuprasellarcisternsandthesphenoid§ Usethecoronalsuture/sphenoidalfontanelleasanacousticwindow§ Usehighdefinition(write)zoom§ ActivatecolourDopplertovisualisetheMCAandassesstheMCAwhichisclosertothetransducer§ MoveanteriorlyandanglebacktoaligntheMCAflowdirectionwiththeDopplerbeam§ Idealinterrogationangleis0degreesbut30degreesorlessisacceptable§ Positionasmall(0.5-1mm)samplevolume2mmbeyondfromtheMCAorigin§ OptimisethespectralDopplerbaselineandPRFtogetalargewaveform§ IftheDopplerangleisnotzero,anglecorrectionmustbeused§ IfPSV>1.5multiplesofthemedian(MoM),obtain3highqualitysamplesandusethehighestvalue
Howtointerpretthetest:
§ >1.5MoMisabnormal
CommonPitfalls:
§ PoorDopplerangleandpooroptimisationleadingtofuzzywaveformwhichishardtomeasure§ GatetooclosetoMCAoriginwheremultidirectionalcontaminationfromACAandPCoAoccurs§ SamplepositionedtooperipherallyintheMCAwherevelocitiesfall§ PCAmisidentifiedasMCA§ Failuretoangle-correctatanglesotherthan0leadingtounderestimationofPSV§ Poorvisualisationduetoinadequatezoom References:
Mari,G.NoninvasiveDiagnosisbyDopplerultrasonographyoffetalanemiaduetomaternalred-cellalloimmunization.NEnglJMed2000;342:9-14,p9-14.Mari,G.Middlecerebralarterypeaksystolicvelocityforthediagnosisoffetalanemia:theuntoldstory.UltrasoundObstetGynecol2005Apr;25(4):323-30.
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MeanuterineArteryPulsatilityIndexIndications:
§ ScreenpatientsathighriskofearlypreeclampsiaorearlySGAat20or24weeks§ Ifabnormalat20weeks,repeatat24weeks§ EarlyonsetIUGR§ Currenthypertensivedisorderinpregnancy§ FullassessmentofsuspectedSGApregnancy
Howtoperformthetest:
§ Locatethematernalanteriorsuperioriliacspineandanglemedially§ Alternativelyvisualizetheexternaliliacartery(EIA)§ TheuterinearteryistypicallyseencrossingtheEIAanteriorly§ SelectaportionoftheuterinearterywhichcoursesatafavourableDopplerangle0-60degrees§ OptimisethespectralDopplerbaselineandPRFtogetalargewaveform§ MeasuretherightandleftPIandcalculatethemeanvalue
Howtointerpretthetest:
§ >95thpercentileisabnormal§ Bilateralnotchingafter24weeksisabnormal
CommonPitfalls:
§ Failuretoidentifytheuterinearterybynotscanninginferiorlyenough
Reference:GomezO.,etal.Referencerangesforuterinemeanpulsatilityindexat11-41weeksofgestation.UltrasoundObstetGynecol2008;32:128-132.
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NewZealandObstetricDopplerGuideline,NZMFMN,revisedOctober2015,Page9
QuickReferenceTables
UmbilicalArteryPIv MCAPIv
CerebroplacentalRatio(CPR)v
MeanUterineArteryPIö
CPR=MCAPI/UAPI MeanPI=(RTPI+LTPI)/2 >95thpercentileisabnormal <5thpercentileisabnormal <5thpercentileisabnormal >95thpercentileisabnormal
GestationWeeks
50thpercentile
95thpercentile
50thpercentile
5thpercentile
50thpercentile
5thpercentile
50thpercentile
95thpercentile
18 1.20 1.7919 1.25Ô 1.63Ô 1.15 1.7020 1.22Ô 1.59Ô 1.10 1.6121 1.15 1.46 1.05 1.5422 1.13 1.43 1.00 1.4723 1.10 1.40 0.96 1.4124 1.08 1.38 1.86 1.38 1.74 1.16 0.93 1.3525 1.06 1.35 1.94 1.44 1.85 1.24 0.89 1.3026 1.04 1.33 2.01 1.50 1.95 1.32 0.86 1.2527 1.02 1.31 2.06 1.55 2.05 1.40 0.84 1.2128 1.00 1.28 2.11 1.58 2.14 1.47 0.81 1.1729 0.98 1.26 2.15 1.61 2.21 1.53 0.79 1.1330 0.96 1.24 2.16 1.62 2.28 1.58 0.77 1.1031 0.94 1.21 2.16 1.62 2.32 1.62 0.75 1.0632 0.92 1.19 2.14 1.61 2.35 1.64 0.73 1.0433 0.90 1.16 2.10 1.58 2.36 1.65 0.71 1.0134 0.88 1.14 2.04 1.53 2.35 1.63 0.70 0.9935 0.86 1.11 1.96 1.47 2.32 1.60 0.69 0.9736 0.84 1.09 1.86 1.39 2.27 1.55 0.68 0.9537 0.81 1.06 1.75 1.30 2.19 1.48 0.67 0.9438 0.79 1.03 1.63 1.20 2.09 1.40 0.66 0.9239 0.77 1.00 1.49 1.10 1.97 1.29 0.65 0.9140 0.75Ô 1.07Ô 1.29ø 1.02ø 1.80ø 1.24ø 0.65 0.90
References:ÔAcharyaG,etal.Referencerangesforserialmeasurementsofbloodvelocityandpulsatilityindexattheintra-abdominalportion,andfetalandplacentalendsofumbilicalartery.UltrasoundObstetGynecol2005;26:162-169. v Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatilityratio:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.øBaschatAA,GembruchU.ThecerebroplacentalDopplerratiorevisited.UltrasoundObstetGynecol2003;21:124-127.ö GomezO,etal.Referencerangesforuterinemeanpulsatilityindexat11-41weeksofgestation.UltrasoundObstetGynecol2008;32:128-132.
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ObstetricDopplerreferencecharts
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Reference:Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatilityratio:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.
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Reference:Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatility:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.
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Reference:Ebbing,C.,Rasmussen,S.,&Kiserud,T.Middlecerebralarterybloodflowvelocitiesandpulsatilityindexandthecerebroplacentalpulsatiliyratio:longitudinalreferencerangesandtermsforserialmeasurements.UltrasoundObstetGynecol,2007.30(3):p.287-96.
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Reference:GomezO.,etal.Referencerangesforuterinemeanpulsatilityindexat11-41weeksofgestation.UltrasoundObstetGynecol2008;32:128-132.
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Reference:Kessler,J.,Rasmussen,S.,Hnson,M.,&Kiserud,T.Longitudinalreferencerangesforductusvenosusflowvelocitiesandwaveformindices.UltrasoundObstetGynecol,2006.28:890-898.
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References:Mari,G.NoninvasiveDiagnosisbyDopplerultrasonographyoffetalanemiaduetomaternalred-cellalloimmunization.NEnglJMed2000;342:9-14,p9-14.
Mari,G.Middlecerebralarterypeaksystolicvelocityforthediagnosisoffetalanemia:theuntoldstory.UltrasoundObstetGynecol2005Apr;25(4):323-30.