1. Farhan Hanif,MD Maternal Fetal Medicine
Doppler in Obstetrics
Farhan Hanif,MD
Maternal Fetal Medicine 1

2. Doppler assessment of the placental and fetal circulation is important tool screening for adverse pregnany outcomes

3. 3

5. Angle Dependence 5

7. 7

8. Doppler in IUGR EFW<10th %ile EFW <2SD above the mean
AC <5th %ile
ACOG defines IUGR as EFW <10thile 8

9. Compensatory Mechanisms
Fetal Hypoxemia- placental insufficiency UA
Blood flow Redistribution
Brain, heart, adrenal Gland
MCA PI AF
Lung, kidney, bowel
Echogenic
Bowel 9

10. Decompensation Pressure in Rt Atrium / Dilatation of DV
Myocardial dysfunction
Pressure in Rt Atrium / Dilatation of DV
Abnormal Venous Doppler 10

11. Fetal Hypoxemia / Acidosis
Abnormalities in
Central Control of FHR
“ANS” or
Direct Myocardial Depression
Variability
Baseline
Deceleration 11

12. 12

13. Abnormal Umbilical vein
Umbilical artery
Abnormal Umbilical vein 13

14. Abnormal Umbilical vein Abnormal Umbilical artery14

15. 15

16. B = “Brain sparing effect”
MCA waveforms
A = Normal
Normal
Brain Sparing
B = “Brain sparing effect” 16

17. MCA Doppler In Anemia In Anemic fetuses, the PSV will inrease.
Obtaining PSV at 0 degrees angle is important in anemic fetuses.
Increase False positive rate after 34 weeks

18. 18

19. 19

20. AGA
IUGR a
IUGR D S 20

21. Role of Ductus Venosus
Baschat et al ultrasound obstet gynecol 2004 21

22. Temporal Sequence of Cardiovascular changes in IUGR fetuses22

23. Ferrazi et al. US Obstet Gynecol 2002; 19: 140-623

24. Doppler Indices and outcomes
In complicated pregnancies abnormal Doppler indices are powerful predictors of adverse perinatal outcome; Low Apgar score Nonreassuring fetal status Low pH Presence of thick meconium Admission to NICU
(late and severe variable decelerations, absent variability,
fetal scalp pH or umbilical cord arterial 24

25. Doppler Indices and outcomes
Reduce perinatal death and unnecessary induction of labor in the preterm growth restricted fetus.
A meta-analysis use of Doppler ultrasonography reduced the odds of perinatal death by 38 percent (95% CI 15-55)
Alfirevic Z et al Am J Obstet Gynecol 1995 25

26. Umbilical Artery
Absence or reversal of end-diastolic flow in the umbilical artery is suggestive of poor fetal condition, whereas normal or slightly decreased umbilical Doppler flow is rarely associated with significant morbidity
and provides strong evidence of fetal well-being when delivery is delayed to achieve further fetal maturity
Ott WJ J Ultrasound Med 2000 26

27. Repeat Doppler in 1-2 weeks
IUGR
Doppler UA and MCA
If Normal
Repeat Doppler in 1-2 weeks
If normal
Serial Growth Scan 4 weeks interval
Doppler UA and MCA every 1-2 weeks
Evaluate MCA at term
?APFS
Consider Delivery at 39 weeks 27

28. Abnormal Doppler UA and MCA
Present
DV Normal
Absent/Reverse
EDF
Ab/Reverse
Present
DV EDF
Growth Scan 2-4 wks
Weekly UA, MCA,+/-DV
Admit
Steroids
NST q shift and daily BPP
Admit
Steroids
Continuous monitoring
May follow as outpatient
BMZ,APFS
Deliver at 32-34wks
Abnormal APFS
?Timing of Delivery
Consider Delivery at weeks 28

29. Absent or Reversed Flow in the Ductus Venosus
EGA
<30weeks
>30weeks
Deliver
Continuous Monitoring
Daily BPP
Daily Doppler
Evaluate AoA, Valves
Deliver for Abnormal BPP,FHT
?Reversed AoA,E:A Ratio 29

30. Doppler in AGA Fetuses
Routine screening with dopplers in AGA fetuses is controversial
However, abnormal UA identifies the fetuses at risk in uncomplicated pregnancies as DM Ch HTN SLE Maternal autoimmune Twins Postterm
Most sensitive 30

31. Uterine Artery Doppler

32. Uterine Artery Doppler
First trimester
Early 2nd Trimester
Late 2nd trimester

34. Prediction of PE Outcome Sensitivity Specificity NPV PE 78 95 99
IUGR <10 23 96
IUGR <3 36 92

35. Prevention Study n Condition Outcome McParland et al 100 PE
ASA 2%, P 19%
Bower et al 60
Severe PE
ASA 13%, P 38%
Morris et al
102
ASA 8%, P 14% (NS)

36. Uterine Artery in 1st trimester
7797 women with singleton pregnancies at 11 to 13 weeks.
In 34 women , at < 34 weeks.
At a 5% FPR;
The sensitivity percent
The specificity was 94.3 percent

37. Doppler in first Trimester
Increases the sensitivity of first trimester screening and decreases the false postivie rate
DV reversed flow in DV in first trimester is a risk factor for CHD even in the presence of normal NT
Can be used as a part of risk calculation for stillbirth
CAN be used as a tool to