DOPPLER IN PREGNANCY

Dr. Ravishankar . P. M.
Color Doppler ultrasound Obstetric and
Gynaecology

Doppler ultrasound has three view of applying in the

Obs & Gynae field.
Directview for example in ovarian torsion or
detecting vascularity of a fibroma.
Easy conceptional view for example to differentiating
a benign ovarian mass from malignant one.
Deep conceptional view for example in detecting
fetal hypoxia & acidosis in pregnancy , congenital
anomalies and tumors , multiple pregnancies,follow
fetal growth.
 Vessels need to be
examined

Umbilical artery
Middle cerebral artery
Uterine artery
Thoracic aorta
IVC
Ductus venosus
Umbilical vein
 Umbilical
artery doppler
Basic Principles
Umbilical arteries arise from
allantoic arteries.
End diastolic flow is often
absent in first trimester.
The high vascular
impedance detected in the
first trimester gradually
decreases.
It is attributed to growth of
placental unit and increase
in the number of the
functioning vascular
channels
 UMBILICAL ARTERY FLOW
Characteristic saw-tooth appearance of
arterial flow in one direction and continuous
umbilical venous blood flow in the other.
Normal Umbilical Artery Doppler
indices
PI {2nd trimester = 2 to
1.5}

PI{ 3rd trimester=1.5

to1}

S/D RATIO = Decrease

as pregnancy advance

Before 28 week <5

28 to 34 week <4

From 34 week to term

<3to3.5
 In IUGR,defective trophoblastic invasion of
vessels- Increased placental vascular
resistance -decreased forward flow in UA-
decreased diastolic flow.

SD ratio, PI and RI all increase

Eventually diastolic flow reaches zero=Absent

End Diastolic Flow(normal in <16 wks)

Further increase in vascular resistance

causes flow reversal in diastole= Reversed
EDF
 UA waveforms are slightly different at
the fetal abdominal wall and at the
placental insertion,with indices higher at
the wall than the insertion.

Though placental insertion is preferred

site for measurement as not influenced by
fetal movement.

In practice, the UA is best examined in

a segment of free floating umbilical cord.
 If there is reversed flow, the UA is
reexamined close to the placental
insertion, because this segment of the
UA is the last part to develop reversed
flow.

Waveforms should be taken in

semilateral position to eliminate forced
respiratory and body movements ,as
they can lead to abnormal waveforms.
Chasing the cord in grey scale will lead to
inadverently large angles of insonation and the
wrong impression of reduced or even absent
EDF.

Magnification of a cord segment followed by use

of colour doppler ,detecting flow velocity in
vertical plane ,allows the pulsed doppler gate to
be placed in each artery with a minimum angle
of insonation.
UA doppler is the tip of iceberg with respect
to fetal hemodynamic state
Doppler shouldnt be done in fetuses with
normal growth
Decisions regarding IUGR are not based on
doppler alone,others factors to be considered
are;
Gestational age
Interval growth and amniotic fluid volume
Nonstress testing and biophysical profile
Maternal factors
Middle cerebral artery
doppler
Normal MCA waveforms

Circle of willis

Normal impedance to flow in first

trimester

Normal impedance to flow in second

trimester
 Middle cerebral artery
The possible doppler velocimetry
sites

Using color flow imaging, the middle cerebral artery

can be seen as a major lateral branch of the circle of
Willis, running anterolaterally at the borderline
between the anterior and the middle cerebral fossa
 Middle cerebral
artery

The blood velocity increases with advancing

gestation, and this increase is significantly
associated with the decrease in PI
 MCA is the vessel of choice because it is
easy to identify , is highly reproducible
and can be easily studied with an angle of
0 degrees providing information on the
true velocity of the blood flow

Averageof both MCAs must be calculated

for more precise result.

Obtain an axial section of the head at the

level of sphenoid bone.
Colour doppler is used to identify circle of
willis with MCA at an angle close to 0
degree.

Enlarge image to see the entire length of

MCA.

Pulsed doppler is applied with a sample

volume of 1 to 2 mm ,samplings should be
taken within 2mm of origin of MCA from
circle of willis.
 S/D ratio of MCA should be >S/D ratio of UA
throughout gestation

In IUGR ,hypoxia leads to autoregulation in fetal

circulation causing increased flow towards
brain, heart and adrenals and decreased
towards kidney, placenta and peripheries.

Autoregulation leads to;

Increase in peak systolic velocity (PSV)
Decrease in S/D ratio,PI,RI ,values
Reversal of S/D ratio (UA>MCA) in IUGR is
called head sparing pattern
 Apparent improvement in MCA PI and S/D
ratio following sustained hypoxia may
occur due to brain edema causing reversal
of head sparing pattern.

So prediction of perinatal mortality is better

done via MCA PSV rather than MCA PI as
PSV shows sustained increase and tends to
show slight decrease but values are
maintained well above the upper limit of
normal until a few hours before delievery or
fetal demise.

Simultaneous improvement of UA tracing

towards normal is better indicator.
UTERINE ARTERY DOPPLER
Uterine artery
Normal uterine artery
waveforms
Normal impedance to flow the
uterine arteries in 1 trimester

Normal impedance to flow the

uterine arteries in early
2trimester

Normal impedance to flow the

uterine arteries in late 2 and 3
trimester
 USES
Ut artery doppler has more of predictive value
for IUGR and PRE-ECLAMPSIA.

Early diastolic notching and reduced or absent

diastolic flow is normal in first trimester.

But endovascular trophoblastic invasion of spiral

arteries leads to decrease in placental vascular
resistance, so after 16 wks of gestation there is
progressive increase in diastolic flow throughout
gestation

So PI,RI and S/D ratio remain low.

 Early diastolic notch should disappear by
25th wk of gestation.

Abnormal UA doppler reveals information

about fetal side while abnormal Ut artery
doppler tells about maternal side.

Both Ut arteries are assessed just after

crossing the iliac vessels and average
measurement is taken,both are taken to
avoid biases due to lateral placental
implantation(lower PI and RI values on
ipsilateral side).
 Defective trophoblastic invasion leads to
increase in RI, PI values.

Presence of notch(decreased velocity in

early diastole) is documented.

If present then whether it is u/l or b/l.

Simultaneous presence of intrasystolic

notch reflects an extremely high
impedance
Uterine artery
Doppler spectra of uterine artery flow. (a) The colour flow image
allows beam/flow angle visualization. The sonogram shows high
velocities throughout the cardiac cycle, indicating low distal
resistance. (b) The sonogram shows a pulsatile flow waveform with
low diastolic velocities. This is indicative of high distal resistance
 Indications for Ut artery
doppler
Previous history of preeclampsia
Previous history of child with
IUGR
Unexplained high maternal
serum AFP level
Unexplained high HCG levels
 Uses of uterine artery
doppler
o IN VITRO FERTILIZATION
If Ut A PI>3.26,very low chance of achieving pregnancy,
tells about receptivity of endometrium for implantation

o RISK ASSESSMENT FOR PRE-ECLAMPSIA AND IUGR

If the PI values of both uterine arteries are normal, the
patient can be informed that she most likely will not
develop preclampsia or have an IUGR fetus, as there is
>99% negative predictive value
but if both are abnormal, patients are followed with more
frequent clinic visits and ultrasounds for growth because
the test has got only 50-75% positive predictive value.
 NORMAL VALUES
VESSELS PI RI

Umbilical artery Early 2nd trimester <0.7

(1.5-2)
Term = 1 (1-1.5)

Middle cerebral artery At 28-32 wks (>1.45) 0.7-0.9

Term =1

Uterine artery 18-22 wks(<1.2) 0.33-0.55

If PI >1.45 with b/l
notching then it
indicates severe
ischaemia.
THORACIC AORTA DOPPLER
FETAL AORTA
 Comment

Acidosis causes peripheral arterial spasm

& rises PI of femoral arteries,
consequently increases thoracic aorta PI.

Iffetal acidosis has an intrinsic cause, it

will be expected that femoral artery PI
will be effected more than umbilical PI.
Waveforms from the fetal descending
aorta are usually recorded at the level of
diaphragm .

The PI is the preferred measurement in the

descending aorta because EDF may be
absent in normal fetuses.
PI of the descending aorta remains
relatively constant throughout gestation
because placental and renal resistance
decreases while lower extremity vascular
resistance increases with advancing
gestation.

Its normal for diastolic flow to decline at

the end of pregnancy k/a term effect.

In severe IUGR ,there is reversed flow in

descending aorta.
DUCTUS VENOSUS DOPPLER
Pathological changes in venous
flows with FGR
INCREASED PLACENTAL RESISTANCE

INCREASED AFTERLOAD TO RIGHT

VENTRICLE(SYSTEMIC VENTRICLE)

RV DECOMPENSATION

TRICUSPID REGURGITATION

BACK PRESSURE TRANSMITTED TO VENOUS SYSTEM

 Ductus venosus is vascular connection from
umbilical vein to IVC .

It is funnel shaped.

Ductus venosus develops at 7 wks gestation

and shows minimal increase in diameter as
a result, diameter of DV is approx 1/3 of
umbilical vein after first trimester so blood
coming through umbilical vein accelerates in
DV and this high velocity flow gets directed
towards left atrium from Rt atrium via
foramen ovale .
 DV waveforms showing reversal of
a wave
 OTHER USES

Abnormal DV waveforms in first trimester

should arise suspicion for

Presence of aneuploidy
Risk of CHD even if chromosomal study
is normal
 Umbilical vein
doppler
Umbilicalvein shows monophasic , continous
non-pulsatile flow after first trimester in
uncomplicated pregnancy.

Itshows pulsatile waveforms at the portal

sinus.

Fetuses with pulsations in the free floating

umbilical vein in the second and third
trimester have a higher morbidity and
mortality, even in the setting of normal UA
blood flow.

Single pulsations correlate with cardiac

systole while double pulsations result from
significant cardiac insufficiency
IVC DOPPLER
IVC
 COMPARISON

NORMAL PATTERN ABNORMAL PATTERN

IVC shows triphasic In IUGR fetuses the IVC

pulsatile waveforms shows increase in
first forward wave reversed flow during
during ventricular systole atrial contraction

second forward wave

during early diastole

third wave characterised

by reversed flow in late
diastole due to atrial
contraction
OTHER USES OF DOPPLER IN
OBS.
In multiple pregnancy
Fetal anomaly
Efffect of medicines on maternal
and fetal circulation
Chronic maternal diseases such as
nephropathy,autoimmune
disease,coagulation
disorders,diabetes and
hypertension
 OTHERS
FETAL ANOMALIES EFFECT OF DRUGS
Doppler used to asses;
Changes in ductus
Vein of galen arteriosus doppler
malformation
Renal agenesis
after use of
Sacrococcygeal
indomethacin for
teratoma
preterm labour and
Sequestration of lung
polyhydramnios(wit
Congenital
h increasing
diapharamatic hernia
severity)
Assesment of a two or raised PSV
three vessel umbilical raised EDV
cord features of TR
VEIN OF GALEN ANEURYSM
RENAL AGENESIS
 SINGLE UMBILICAL ARTERY
It is diagnosed by
imaging the origin of
umbilical artery adjacent
to fetal urinary bladder.

ASSOCIATIONS:
1. Chromosomal
defects(autosomal
trisomies)
2.Cardiac and renal
anomalies
3.Normal variant(1%)
 CORD COILING AROUND
NECK
Generally harmless.
Multiple(>2) loops of
nuchal cord observed
in
3rd trimester are
relevant especially in
breech presentation
because then
External
Cephalic Version is
3 FOLD NUCHAL CORD
 The best predictor of fetal hypoxia is PI of MCA.
BPP has a limited role for assessing fetal well
being before 32 gestational weeks.
Doppler ultrasound can predict fetal distress
sooner than BPP.
The best predictor for fetal acidemia is PI of
thoracic aorta.
Reverse flow in the umbilical artery, along with
pathologic waveform in the venous system are
the best predictor of severe fetal distress, so
termination of pregnancy must be considered
as soon as possible.
 Conclusion
Doppler US assessment of the UA has
become a standard of care for fetuses with
IUGR, which helps to decrease the
perinatal mortality in high risk pregnancies
.

Doppler US of the MCA has become the

standard care for the diagnosis of fetal
anaemia, thus avoiding unnecessery
invasive procedures.