1. To Doppler or not to Doppler
Ivica Zalud, MD, PhD
Community Collaborations:
Obstetrics, Genetics and Ultrasound
December 14-15, 2018

2. Objectives Describe Doppler technique in different blood vessels
Discuss Doppler role in IUGR fetuses
Understand the value of Doppler in fetal anemia
Present Doppler frontiers

4. The Doppler Effect

5. Doppler Ultrasound

6. Color Doppler

7. 3D Doppler

8. Clinical Applications
Common applications (IUGR)
Other applications (fetal anemia)
New applications
3D Doppler

9. Doppler in IUGR
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;

10. Umbilical Artery Low impedance circulation S/D index (A/B index)
Placental insertion has least impedance
Intervene for absent or reversed EDF

11. UA Doppler – reversed diastolic flow
This is an advanced stage of fetal compromise, associated with increased perinatal morbidity and mortality.

12. MCA Doppler Most accessible cerebral vessel
Carries 80% of cerebral flow
Excellent reproducibility

13. MCA Doppler
Normal
Abnormal – fetal hypoxia

14. Venous Circulation Central: ductus venosus, hepatic veins, IVC
– characteristic pulsations
Peripheral:
portal veins, umbilical vein
– no pulsations

15. Ductus venosus turbulence (DV)
Umbilical vein DV
IVC

16. Normal Fetus
IVC Doppler
DV Doppler

17. Hypoxic Fetus
IVC Doppler
DV Doppler

18. Uterine Circulation Low impedance circulation in pregnancy
S/D or RI – standard indices
Low EDF & notching – abnormal findings
Associated with elevated MS AFP & hCG

19. Uterine Artery Abnormal waveforms: IUGR Pre-eclampsia
FHR abnormalities

20. IUGR Challenge: Diagnose true IUGR Identify markers of morbidity
Intervene in a timely fashion

21. middle cerebral artery ductus venosus.
Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol Apr;206(4):300-8.
Relevant studies in English identified using PubMed (US National Library of Medicine, 1983 through 2011) which describe the peripartum outcomes of IUGR according to Doppler assessment of:
umbilical arterial
middle cerebral artery
ductus venosus.

22. Randomized and quasi-randomized studies
Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol Apr;206(4):300-8.
Randomized and quasi-randomized studies
UA Doppler significantly decreases the likelihood (1.2% vs 1.7%; RR, 0.71; 95% confidence interval, ).
labor induction
cesarean delivery
perinatal deaths
Antepartum surveillance with UA Doppler should be started when the fetus is viable and IUGR is suspected.

23. Berkley E, Chauhan SP, Abuhamad A
Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol Apr;206(4):300-8.
Although Ductus venous, MCA and other vessels have some prognostic value for IUGR fetuses, there is a lack of randomized trials showing benefit.
Doppler studies of vessels other than the UA, as part of assessment of fetal well-being in pregnancies complicated by IUGR, should be reserved for research protocols.

24. Delivery
The optimal timing of delivery depends on the underlying etiology of the growth restriction (if known) as well as the estimated gestational age.
The patient makes informed decision

25. GRIT Trial
BJOG 2003;110:27–32
Lancet 2004;364:513–20
AJOG 2011;204:34.e1–34.e9
The only published randomized trial to assess the timing of delivery of the early preterm (<34 weeks) IUGR fetus.
Pts whose OBs were uncertain whether delivery would be beneficial, were randomized:
early delivery group (delivery within 48 hours) or
expectant management group (with antepartum surveillance until it was felt that delivery should not be delayed any longer).

26. GRIT Trial
BJOG 2003;110:27–32
Lancet 2004;364:513–20
AJOG 2011;204:34.e1–34.e9
The rates of betamethasone administration were the same in both groups.
Perinatal survival was similar.
At the 6–12-year follow-up there were no differences in cognitive, language, behavior, or motor abilities of the children born to women in the early-delivery group versus those in the expectant management group.

27. DIGIT Trial
In the Disproportionate Intrauterine Growth Intervention Trial at Term, women with singleton gestations at or beyond 36 weeks with suspected IUGR were randomized:
undergo delivery or
expectant management with delivery only if some other indication arose.
BMJ 2010;341:c7087.

28. DIGIT Trial
There were no differences in composite neonatal outcome between these two groups.
The study cohort was not large enough to determine whether individual outcomes, such as perinatal death, were affected by the different management approaches.
BMJ 2010;341:c7087.

29. Delivery: NICHD, SMFM, ACOG
Existing data and expert consensus, a joint conference of the NICHD , SMFM and ACOG suggested the following two timing strategies:
1) Delivery at 38 0/7–39 6/7 weeks of gestation in cases of isolated fetal growth restriction
Obstet Gynecol 2011;118:323–33.

30. Delivery: NICHD, SMFM, ACOG
2) Delivery at 34 0/7–37 6/7 weeks of gestation in cases of IUGR with additional risk factors for adverse outcome
oligohydramnios
abnormal umbilical artery Doppler
maternal risk factors
comorbidities
Obstet Gynecol 2011;118:323–33.

31. Delivery: NICHD, SMFM, ACOG
3) Delivery before 34 weeks
At a center with a NICU and, ideally, after consultation with a maternal–fetal specialist.
Corticosteroids should be administered before delivery (improved preterm neonatal outcomes).
For cases in which delivery occurs before 32 weeks of gestation, magnesium sulfate should be considered for fetal and neonatal neuroprotection
Obstet Gynecol 2011;118:323–33.

32. TERM IUGR Mode of delivery
Based entirely on standard obstetric practice
No evidence to support routine C/S
Consideration for C/S if non-reassuring antepartum testing with an unfavorable cervix
Labor induction with or without cx ripening
Continuous electronic fetal monitoring
FHR monitor: Increased risk for decreased variability and late decelerations
Meconium
Optimum: Tertiary care centers with MFM and NICU available

33. Evidence –based national guidelines for management of suspected fetal growth restriction: comparison, consensus and controversy McCowan LM et all. Am J Obstet Gynecol 2018:S

34. McCowan LM et all. Am J Obstet Gynecol 2018:S855-868

35. McCowan LM et all. Am J Obstet Gynecol 2018:S855-868

36. McCowan LM et all. Am J Obstet Gynecol 2018:S855-868

37. McCowan LM et all. Am J Obstet Gynecol 2018:S855-868

38. Cerebroplacental Ratio (CPR) G.DeVore AJOG July 2015;213:5-15
Emerging as important predictor of adverse pregnancy outcome
Abnormal CPR in AGA fetuses or late IUGR (>34 weeks)
Higher incidence of distress in labor (more c/s)
Lower cord pH
Increased NICU admissions

39. Cerebroplacental Ratio (CPR) G.DeVore AJOG July 2015;213:5-15
Abnormal CPR in early IUGR (<34 weeks)
Lower GA at birth
Lower mean BW and lower BW centile
Higher c/s rate for distress in labor
Higher rate of 5 min Apgar <7
Increased rate of neonatal acidosis
Increased rate of NICU admissions
Higher rate of adverse neonatal outcome
Greater incidence of perinatal death

40. Doppler & Fetal Anemia Anemia: Why MCA? 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

41. Doppler & Fetal Anemia MCA PSV: Moderate to severe anemia: Parvo virus
Sensitivity 100%
FPR 12%
Mari C et al. NEJM 2000;342:9
Parvo virus
Sensitivity 94.1%
Specificity 93.3%
ACOG 2002

42. New Applications Umbilical artery notching: JUM 2002;21:857
Cord entanglement
True knot
Cord stricture
Velamentous insertion
Tight nuchal cords
Abnormal cord coiling
JUM 2002;21:857

43. Placenta - 3D Doppler

44. Vascularization Index (VI)
VI = measures % of color pixels in ROI that represent flow

45. 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)

46. 3-D Calculations Measurement Measurement Measurement 60 degrees

47. Pre-eclampsia, IUGR, placenta accreta

48. Placental vasculature: 3D power Doppler angiography and 3D color Doppler imaging
Campbell S. Ultrasound Obstet Gynecol 2007;30(6):  

49. Evaluation of the utero-placental circulation by 3D Doppler ultrasound in the second trimester of normal pregnancy
Significant difference among placental VI, FI and VFI related to gestational age at the time of the ultrasound exam. The same was true for spiral arteries ultrasound measurements. (F=0.219; P=0.954)
Placental vascular indices slowly increased indicating progressive development of vascular network and increase in the volume blood flow.
Zalud I, Shaha S: J Matern Fetal Neonat Med 2007;20:299–305.

50. 3D Doppler of the placenta and spiral arteries: Influence of maternal age and parity
Zalud I, Shaha S: J Clin Ultrasound May 2.
The parity influenced all placental 3D Doppler indices (larger indices in multipara).
Maternal age influenced the spiral arteries volume (larger volume in patients younger
than 25).

51. Placenta Accreta:
3D Doppler

52. Small is the new big…
Are you ready for the future?

53. ? 4D Doppler

54. Conclusions
Doppler ultrasound is integral part in management of IUGR, fetal anemia and placental abnormalities.
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.

55. Mahalo Nui Loa! Thank you!