Doppler ultrasound of the umbilical artery for fetal surveillance
- Dev Maulik, MD, PhD
Dev Maulik, MD, PhD
- Professor and Chair of Obstetrics and Gynecology
- Senior Associate Dean for Women's Health
- The University of Missouri-Kansas City (UMKC) School of Medicine
- Section Editors
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Co-Chief of Ultrasound
- Beth Israel Deaconess Medical Center
Doppler sonography is used for non-invasive assessment of circulation in many clinical conditions. This technique has been used for studying most of the major fetal circulatory systems, including the umbilical artery (UA) , umbilical vein , aorta , heart , and middle cerebral artery . Doppler sonography provides a unique opportunity to investigate human fetal hemodynamics and to use these findings for fetal surveillance.
This topic will discuss Doppler sonography of the umbilical artery. In high-risk obstetrical populations, meta-analyses of randomized trials have shown that fetal umbilical artery Doppler is an effective test for improving perinatal mortality and morbidity .
PHYSICS OF DOPPLER ULTRASOUND
Doppler frequency shift refers to the change in frequency of energy wave transmission observed when relative motion occurs between the source of wave transmission and the observer. An ultrasound (U/S) beam encountering circulating blood is scattered by millions of red cells, which cause the incident beam to undergo a frequency shift proportional to the speed of red cell movement (ie, blood flow velocity). This relationship is expressed in the Doppler equation (figure 1) . If the Doppler shift and the angle of beam incidence are known, and assuming that the transducer frequency and the velocity of sound in tissue remain relatively constant, then the velocity of blood flow can be determined from the following modification of the above equation: v = fd.c / 2 ft.cos q . This equation forms the basis for clinical application of the Doppler principle.
MODALITIES OF DOPPLER ULTRASOUND
Clinical implementations of Doppler ultrasound technology for assessing circulation include continuous wave (CW), pulsed wave (PW), and color Doppler. CW and PW Doppler modes are also known as spectral Doppler. These modalities can also be used to evaluate tissue movement and strain, and are known as tissue Doppler imaging.
Continuous wave — Continuous wave Doppler ultrasound is used extensively in obstetrics for determining and monitoring the fetal heart rate, but cannot identify the exact location of the origin of the Doppler signals in the ultrasound beam path. Free-standing CW devices with a spectral analyzer had been used for insonating the umbilical arteries for velocimetric applications, but PW Doppler has replaced these devices.
- FitzGerald DE, Drumm JE. Non-invasive measurement of human fetal circulation using ultrasound: a new method. Br Med J 1977; 2:1450.
- Gill RW. Pulsed Doppler with B-mode imaging for quantitative blood flow measurement. Ultrasound Med Biol 1979; 5:223.
- Eik-Nes, SH, Brubakk, AO, et al. Measurement of human fetal blood flow. Br Med J 1980; 28:283.
- Maulik D, Nanda NC, Saini VD. Fetal Doppler echocardiography: methods and characterization of normal and abnormal hemodynamics. Am J Cardiol 1984; 53:572.
- Arbeille, P, Tranquart, F, Body, G, et al. Evolution de la circulation arterielle ombilicale et cerebrale du foctus au cours de la grossesse. Progres en Neonatologie 1986; 6:30.
- Maulik D, Mundy D, Heitmann E, Maulik D. Evidence-based approach to umbilical artery Doppler fetal surveillance in high-risk pregnancies: an update. Clin Obstet Gynecol 2010; 53:869.
- Stuart B, Drumm J, FitzGerald DE, Duignan NM. Fetal blood velocity waveforms in normal pregnancy. Br J Obstet Gynaecol 1980; 87:780.
- Pourcelot, L. Applications clinique de 1'examen Doppler transcutane In: Pourcelot, L(Ed): Velocimetric Ultrasonore Doppler 1974; 34:213.
- Maulik D, Yarlagadda AP, Youngblood JP, Willoughby L. Components of variability of umbilical arterial Doppler velocimetry--a prospective analysis. Am J Obstet Gynecol 1989; 160:1406.
- Mires G, Dempster J, Patel NB, Crawford JW. The effect of fetal heart rate on umbilical artery flow velocity waveforms. Br J Obstet Gynaecol 1987; 94:665.
- Yarlagadda P, Willoughby L, Maulik D. Effect of fetal heart rate on umbilical arterial Doppler indices. J Ultrasound Med 1989; 8:215.
- Abramowicz JS, Warsof SL, Arrington J, Levy DL. Doppler analysis of the umbilical artery. The importance of choosing the placental end of the cord. J Ultrasound Med 1989; 8:219.
- Society for Maternal-Fetal Medicine Publications Committee, Berkley E, Chauhan SP, Abuhamad A. Doppler assessment of the fetus with intrauterine growth restriction. Am J Obstet Gynecol 2012; 206:300.
- van Eyck J, Wladimiroff JW, van den Wijngaard JA, et al. The blood flow velocity waveform in the fetal internal carotid and umbilical artery; its relation to fetal behavioural states in normal pregnancy at 37-38 weeks. Br J Obstet Gynaecol 1987; 94:736.
- van Eyck J, Wladimiroff JW, Noordam MJ, et al. The blood flow velocity waveform in the fetal descending aorta; its relationship to behavioural states in the growth-retarded fetus at 37-38 weeks of gestation. Early Hum Dev 1986; 14:99.
- Maulik D. Hemodynamic interpretation of the arterial Doppler waveform. Ultrasound Obstet Gynecol 1993; 3:219.
- Krebs C, Macara LM, Leiser R, et al. Intrauterine growth restriction with absent end-diastolic flow velocity in the umbilical artery is associated with maldevelopment of the placental terminal villous tree. Am J Obstet Gynecol 1996; 175:1534.
- Kingdom J, Huppertz B, Seaward G, Kaufmann P. Development of the placental villous tree and its consequences for fetal growth. Eur J Obstet Gynecol Reprod Biol 2000; 92:35.
- Salafia CM, Pezzullo JC, Minior VK, Divon MY. Placental pathology of absent and reversed end-diastolic flow in growth-restricted fetuses. Obstet Gynecol 1997; 90:830.
- Spinillo A, Gardella B, Bariselli S, et al. Placental histopathological correlates of umbilical artery Doppler velocimetry in pregnancies complicated by fetal growth restriction. Prenat Diagn 2012; 32:1263.
- Morrow RJ, Adamson SL, Bull SB, Ritchie JW. Effect of placental embolization on the umbilical arterial velocity waveform in fetal sheep. Am J Obstet Gynecol 1989; 161:1055.
- Wilcox GR, Trudinger BJ, Cook CM, et al. Reduced fetal platelet counts in pregnancies with abnormal Doppler umbilical flow waveforms. Obstet Gynecol 1989; 73:639.
- Peeters LL, Sheldon RE, Jones MD Jr, et al. Blood flow to fetal organs as a function of arterial oxygen content. Am J Obstet Gynecol 1979; 135:637.
- Visser, GH, Stigter, RH. Monitoring the growth retarded fetus. In Asphyxia and Fetal Brain Damage. Maulik, D (Ed), Springer International, New York 1997. p. 333.
- Ribbert LS, Visser GH, Mulder EJ, et al. Changes with time in fetal heart rate variation, movement incidences and haemodynamics in intrauterine growth retarded fetuses: a longitudinal approach to the assessment of fetal well being. Early Hum Dev 1993; 31:195.
- Williams KP, Farquharson DF, Bebbington M, et al. Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial. Am J Obstet Gynecol 2003; 188:1366.
- Bilardo CM, Nicolaides KH, Campbell S. Doppler measurements of fetal and uteroplacental circulations: relationship with umbilical venous blood gases measured at cordocentesis. Am J Obstet Gynecol 1990; 162:115.
- Yoon BH, Romero R, Roh CR, et al. Relationship between the fetal biophysical profile score, umbilical artery Doppler velocimetry, and fetal blood acid-base status determined by cordocentesis. Am J Obstet Gynecol 1993; 169:1586.
- Valcamonico A, Danti L, Frusca T, et al. Absent end-diastolic velocity in umbilical artery: risk of neonatal morbidity and brain damage. Am J Obstet Gynecol 1994; 170:796.
- Soothill PW, Nicolaides KH, Bilardo K, et al. Utero-placental blood velocity resistance index and umbilical venous pO2, pCO2, pH, lactate and erythroblast count in growth-retarded fetuses. Fetal Ther 1986; 1:176.
- Karsdorp VH, van Vugt JM, van Geijn HP, et al. Clinical significance of absent or reversed end diastolic velocity waveforms in umbilical artery. Lancet 1994; 344:1664.
- Maulik, D, Absent End Diastolic Velocity In The Umbilical Artery And Its Clinical Significance. In: Doppler Ultrasound in Obstetrics and Gynecology, 2nd ed, Maulik, D (Ed), Springer-Verlag, New York 2005.
- Gratacós E. The problem of predicting neurological outcome in early-onset intrauterine growth restriction. Ultrasound Obstet Gynecol 2009; 33:5.
- Maulik, D, Figueroa, R. Doppler velocimetry for fetal surveillance: randomized clinical trials and implications for practice. In: Doppler Ultrasound in Obstetrics and Gynecology, Maulik D. (Ed), Springer, 2005. p.387.
- Alfirevic Z, Stampalija T, Gyte GM. Fetal and umbilical Doppler ultrasound in high-risk pregnancies. Cochrane Database Syst Rev 2013; 11:CD007529.
- Bricker L, Neilson JP. Routine doppler ultrasound in pregnancy. Cochrane Database Syst Rev 2000; :CD001450.
- A randomised controlled trial of Doppler ultrasound velocimetry of the umbilical artery in low risk pregnancies. Doppler French Study Group. Br J Obstet Gynaecol 1997; 104:419.
- American College of Obstetricians and Gynecologists. Intrauterine growth restriction. ACOG Practice Bulletin 12. American College of Obstetricians and Gynecologists, Washington, DC 2000.
- Maulik D, Yarlagadda P, Youngblood JP, Ciston P. The diagnostic efficacy of the umbilical arterial systolic/diastolic ratio as a screening tool: a prospective blinded study. Am J Obstet Gynecol 1990; 162:1518.
- Devoe LD, Gardner P, Dear C, Faircloth D. The significance of increasing umbilical artery systolic-diastolic ratios in third-trimester pregnancy. Obstet Gynecol 1992; 80:684.
- GRIT Study Group. A randomised trial of timed delivery for the compromised preterm fetus: short term outcomes and Bayesian interpretation. BJOG 2003; 110:27.
- Thornton JG, Hornbuckle J, Vail A, et al. Infant wellbeing at 2 years of age in the Growth Restriction Intervention Trial (GRIT): multicentred randomised controlled trial. Lancet 2004; 364:513.
- Simonazzi G, Curti A, Cattani L, et al. Outcome of severe placental insufficiency with abnormal umbilical artery Doppler prior to fetal viability. BJOG 2013; 120:754.
- PHYSICS OF DOPPLER ULTRASOUND
- MODALITIES OF DOPPLER ULTRASOUND
- Continuous wave
- Pulsed wave
- Color flow mapping
- Tissue Doppler imaging
- SAFETY IN PREGNANCY
- DOPPLER WAVEFORM ANALYSIS
- Factors affecting the waveform
- CORRELATION BETWEEN DOPPLER, ANATOMIC, AND CLINICAL FINDINGS
- AEDV AND REDV
- CLINICAL EFFECTIVENESS
- GUIDELINES FOR CLINICAL PRACTICE
- Clinical interpretation
- Management with normal Doppler indices
- Management with abnormal Doppler indices
- SUMMARY AND RECOMMENDATIONS