|Year : 2015 | Volume
| Issue : 2 | Page : 79-82
Study on role of obstetrical Doppler in pregnancies with hypertensive disorders of pregnancy
Chhakchhuak Lalthantluanga1, Ningthoukhongjam Romita Devi1, Ningombam Jitendra Singh1, Ningthoukhongjam D Shugeta2, Victor Khuman1, Shangchungla Keishing1
1 Department of Obstetrics and Gynaecology, Regional Institute of Medical Sciences, Imphal, Manipur, India
2 MD Community Medicine, MO Manipur Health Services, Manipur, India
|Date of Web Publication||20-Aug-2015|
Ningthoukhongjam Romita Devi
Department of Obstetrics and Gynaecology, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Objectives: To study Doppler velocimetry of umbilical artery (UA) and middle cerebral artery (MCA) in hypertensive disorders of pregnancy (HDP) and analysis of association of abnormal Doppler waveform with perinatal outcome. Materials and Methods: Doppler velocimetry of fetal UA and MCA were studied in 100 pregnant women with hypertensive disorders of pregnancy. The results were analysed to find out perinatal outcome in those with abnormal Doppler studies. Results: The result of this study showed that fetuses with UA Systolic/Diastolic (SD) ratio >3 were associated with poor perinatal outcome in 89.65% with sensitivity and specificity of 80.00% and 82.86% respectively. Fetuses with cerebro-placental index (CPI) ≤1 have poor perinatal outcome in 95.74% with higher specificity (93.94%) and positive predictive value (95.74%). Conclusion: Fetuses with abnormal Doppler velocimetry had a significantly higher incidence of low birth weight babies, low apgar score, meconium stained liquor, intrauterine growth restriction (IUGR), admission to neonatal intensive care unit (NICU), intrauterine death (IUD)/still birth and shorter period of gestation at delivery.
Keywords: CPI, Doppler velocimetry, perinatal outcome, UA S/D ratio
|How to cite this article:|
Lalthantluanga C, Devi NR, Singh NJ, Shugeta ND, Khuman V, Keishing S. Study on role of obstetrical Doppler in pregnancies with hypertensive disorders of pregnancy. J Med Soc 2015;29:79-82
|How to cite this URL:|
Lalthantluanga C, Devi NR, Singh NJ, Shugeta ND, Khuman V, Keishing S. Study on role of obstetrical Doppler in pregnancies with hypertensive disorders of pregnancy. J Med Soc [serial online] 2015 [cited 2021 Apr 17];29:79-82. Available from: https://www.jmedsoc.org/text.asp?2015/29/2/79/163195
| Introduction|| |
Throughout the world, 585,500 women die every year as a result of pregnancy and childbirth. Over 98% of all maternal mortality occurs in the developing countries. , In developing countries, 17% of direct obstetric deaths are as a result of hypertension.  Hypertension is reported to account for 15% of all antenatal hospitalizations for pregnancy complications in the United States.  Depending on the region, between 9.1% (Africa, Asia), 16.1% (developed countries), and 25.7% (Latin America) of maternal deaths may be attributed to pregnancy associated hypertension.  About 18% of fetal deaths are associated with hypertensive disorders.  Pregnancy induced hypertension is responsible for 15% of all direct maternal deaths in UK while it accounts for 24% of maternal death in India. 
Doppler velocimetry is a non invasive technology which uses the Doppler principle to analyze the properties of blood flow in vessel of interest.  Doppler studies on different vessels have been practiced worldwide. Abnormal Doppler waveforms in multiple vessels have been found frequently in pregnancies with HDP. Both abnormal umbilical Doppler indices and cerebral-umbilical ratio are strong predictors of IUGR and of adverse perinatal outcome in preeclampsia. Hence, hypertension in pregnancy though may complicate only around 5 to 10% of pregnancy, has a strong affect on the maternal and also to the fetal mortality and morbidity. The condition has been found quite often and patients with preeclampsia have also been admitted quite frequently for further closer monitoring and management.
Therefore, assessment of umbilical artery and middle cerebral artery Doppler waveforms in those pregnant women with hypertension has been conducted to study the incidences of abnormal Doppler Waveform changes and the pattern of changes in pregnancies complicated with HDP and also its correlation with the perinatal outcome in those showing abnormal waveform.
| Materials and methods|| |
It is an observational prospective study done for a period of one and half years from October 2011 to March 2013. After getting clearance from Ethics Committee, RIMS, one hundred pregnant women with hypertensive disorders of pregnancy attending Department of Obstetrics and Gynecology, either in the OPD or admitted in the ward at gestation age of ≥24 weeks, and were willing to participate in the study were referred to the Department of Radiodiagnosis, Regional Institute of Medical Sciences (RIMS), Imphal for Doppler study of umbilical and middle cerebral arterial blood flow to find out the doppler waveforms incidences and the pattern of abnormal Doppler waveform changes. With the women in lying supine position, the umbilical artery was localized by real time ultrasonographic scanner of 3.5 MHz transducer (Siemens Versa Plus colour Doppler Ultrasound machine). Then the Doppler waveforms were recorded from the umbilical artery. Once the equal wave of at least five consecutive pulsatile arterial waveforms is obtained, the image is frozen and the S/D ratios, Pulsatililty Index (PI) and Resistance Index (RI) were calculated during the absence of fetal breathing and body movement. Presence or Absence of Reduced End Diastolic Flow, Absent End Diastolic Flow or Reversed End Diastolic Flow was noted.
Doppler study of the MCA was performed to find out any increased diastolic flow suggested of 'brain sparing effect' in compromised fetuses. Doppler study was done on the admission day and was repeated depending on the positive findings. On an average, three readings were taken from those who had positive findings. Last Doppler study before delivery was used for calculation.
UA S/D ratio more than or equal to 3 was considered abnormal after 30 weeks of period of gestation.CPI is calculated by dividing MCA resistance index by UA resistance index (CPI = RI MCA/ RI UA). A CPI ≤1 was considered abnormal.
The patients showing abnormal Doppler waveform changes were admitted at Antenatal Ward of Obstetrics and Gynecology department, RIMS, Imphal, and were followed-up till delivery or post delivery period during their hospital stay. Fetal outcome was determined by the presence or absence of IUGR, intrauterine fetal death/ still birth, meconium stained liquor, Apgar score ≤7 at 5 minutes, operative delivery for fetal distress, requirement of NICU admission, low birth weight, and also period of gestation at time of delivery. Those fetuses who met any of the above parameters were labeled as having poor outcome. Others were considered as having good outcome.
Statistical analysis was done by SPSS 16, using Chi- square test and t- test.
| Results|| |
Out of hundred pregnant women with hypertension, 58% showed UA S/D ratio ≥3 and 42% of the study group showed UA S/D ratio <3. 46% of the study group showed CPI <1 and 54% showed CPI >1. Reduced end diastolic flow, absent end diastolic flow and reversed end diastolic flow were found in 14%, 9% and 5% respectively. Fetuses with UA S/D ratio <3 had mean period of gestation of 38.36 ± 0.52 weeks and mean birth weight of 3.029 ± 0.39 gm while those with UA S/D ratio ≥3 had mean period of gestation of 36.74 ± 2.39 weeks and mean birth weight of 2.369 ± 0.66 gm. Fetuses with UA S/D ratio <3 had IUGR in 14.3%, meconium stained amniotic fluid in 16.70%, Apgar score at 5 minutes in 16.70%, while fetuses with UA S/D ratio ≥3 had IUGR in 41.40%, meconium stained liquor in 50.00%, Apgar score at 5 minutes in 44.8%. Fetuses with UA S/D ratio <3 resulted in NICU admission in 19% while UA S/D ratio ≥3 resulted in NICU admission in 56.90%.
Fetuses with UA S/D ratio <3 resulted in IUD/Still birth in 9.5% while UA S/D ratio ≥3 resulted in IUD/Still birth in 25.9%.
[Table 1] showed fetal events in relation to CPI ratio <1 and >1 and were found to be statistically significant.
[Table 2] showed fetuses with UA S/D ratio ≥3 had poor perinatal outcome in 89.65% while fetuses with UA S/D ratio <3 had poor perinatal outcome in 30.95% only. The sensitivity, specificity, Positive predictive value and negative predictive value of UA S/D ratio in relation to poor perinatal outcome are statistically calculated as below:
Positive predictive value −89.66%
Negative predictive value −69.05%
|Table 2: Evaluation of UA S/D ratio as predictor of poor perinatal outcome|
Click here to view
[Table 3] showed fetuses with CPI <1 had poor perinatal outcome in 95.74% while fetuses with CPI >1 had poor perinatal outcome in 39.21%. The sensitivity, specificity, Positive predictive value and negative predictive value of CPI in relation to poor perinatal outcome are statistically calculated as below:
Positive predictive value −95.74%
Negative predictive value −60.78%
| Discussion|| |
In the present study, 58% showed abnormal umbilical artery Doppler study (S/D ratio ≥3) and is comparable with other study. The sensitivity, specificity, positive predictive value and negative predictive value of abnormal umbilical doppler as predictor of poor perinatal outcome was 80.00%, 82.86%, 89.66% and 69.05% respectively. This result was comparable with the result of Fleischer et al. (1985)  who observed UA S/D ratio ≥3 with sensitivity of 78%, specificity of 83%, positive predictive value of 66% for predicting adverse perinatal outcome in pregnancy with hypertension.
CPI was abnormal in 46% (CPI ≤1) in the present study and had 69.23% sensitivity, 93.94% specificity, 95.74% positive predictive value and 60.78% negative predictive value respectively for predicting poor perinatal outcome. This is also comparable with the study of Alla et al. (2005)  in their series of 50 preeclamptic women with or without IUGR, wehere they observed that the CPI had 64.1% sensitivity, 72.7% specificity, 89.2% positive predictive value and 36.3% negative predictive value for fetal morbidity. Zhang  in their study in 1993 observed that CPI <1 had a higher prognostic value for predictor of poor perinatal outcome than umbilical artery FVW alone.
| Conclusion|| |
Hypertensive disorder of pregnancy is one of the leading causes of maternal mortality and is responsible for a considerable amount of perinatal morbidity and mortality. Doppler ultrasound velocimetry of uteroplacental, umbilical and fetal vessels provides important information on the haemodynamics of the vascular area under study and its use appears to improve a number of obstetric care outcomes and promising in reducing perinatal deaths.
Fetuses with abnormal Doppler velocimetry had a significantly higher incidence of low birth weight babies, low apgar score, meconium stained liquor, IUGR, admission to NICU, IUD/still birth and shorter period of gestation at delivery. Doppler data combining both umbilical and cerebral velocimetry provide additional information on fetal consequences of the placental abnormality. Doppler velocimetry studies of placental and fetal circulation can provide important information regarding fetal well-being, yielding an opportunity to improve fetal outcome. Doppler velocimetry has proved to reliably predict any adverse fetal outcome in hypertensive pregnancies and can be an useful tool for taking decision in the appropriate timing of intervention for delivery. It can be concluded that every obstetrician must be aware of the feasibility of obstetrical doppler velocimetry which may be an aid to plan the treatment and undertake timely intervention thereby reducing perinatal morbidity and mortality.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
AbouZahr C, Royston E. Maternal mortality: a global factbook. WHO/MCH/MSM 91.3. Geneva: World Health Organisation, 1991.
Bates I, Chapotera GK, McKew S, van den Broek N. Maternal mortality in sub-Saharan Africa: The contribution of ineffective blood transfusion services. Int J Obstet Gynaecol 2008;115:1331-9.
Maine D, Rosenfield A, Wallace M, Kimball AM, Kwast B, Papiernik E, et al
. Prevention of maternal deaths in developing countries: Program options and practical considerations. Nairobi: Paper Presented at the International Safe Motherhood Conference; 1987. p. 10-3.
Scott CL, Chavez GF, Atras HK, Taylor DJ, Shah RS, Rowley D. Hospitalizations for severe complications of pregnancy, 1987-1992. Obstet Gynecol 1997;90:225-9.
Khan KS, Wojdyla D, Say L, Gulmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: A systematic review. Lancet 2006;367:1066-74.
Cnossen JS, van der Post JA, Mol BW, Khan KS, Meads CA, ter Riet G. Prediction of pre-eclampsia: A protocol for systematic reviews of test accuracy. BMC Pregnancy Childbirth 2006;6:29.
Bedi N, Kamboj I, Dhillon BS, Saxena BN, Singh P. Maternal death in India-Preventable tragedies (An ICMR task Force Study). J Obstet Gynecol Ind 2001;52:86-92.
Arias F, Daftary SN, Bhide AG. Practical Guide to High Risk Pregnancy and Delivery: A South Asian Perspective. 3 rd
ed. New Delhi: Elsevier; 2010. p. 22-6.
Fleischer A, Schulman H, Farmakides G, Bracero L, Blattner P, Randolph G. Umbilical artery velocity waveforms and intrauterine restriction. Am J Obstet Gynecol 1985;151:502-5.
Ebrashy A, Azmy O, Ibrahim M, Waly M, Edris A. Middle cerebral/Umbilical Artery resistive index as sensitive parameter for fetal wellbeing and neonatal outcome in patients with pre eclampsia: Case-control study. Croat Med J 2005;46:821-5.
Zhang YN. Clinical evaluation of fetal blood flow velocity in cerebral artery and umbilical artery by color Doppler imaging. Zhonghua Fu Chan Ke Za Zhi 1993;28:395-6, 440-1.
[Table 1], [Table 2], [Table 3]