DOPPLER

ULTRASOUND IN
OBSTETRICS
Circulation Year Author
Umbilical artery 1977 FitzGerald and Drumm
Umbilical vein 1979 Gill and Kossoff [24]
Fetal aorta 1980 Eik-Nes et al. [25]
Uteroplacental 1983 Campbell et al. [26]
Fetal inferior vena cava 1983 Chiba et al. [27]
Fetal cardiac 1984 Maulik et al. [28]
Fetal cerebral 1986 Arbeille et al. [29]
1986 Wladimiroff et al. [30]
Fetal ductus arteriosus 1987 Huhta et al. [31]
Fetal renal 1989 Vyas et al. [32]
1989 Veille and Kanaan [33]
Fetal ductus venosus 1991 Kiserud et al. [35]
Fetal coronary artery 1996 Gembruch et al. [36]
 DOPPLER ULTRASOUND IN
OBSTETRICS
Introduction

 Doppler assessment of the placental circulation plays an

important role in screening for impaired placentation and
its complications of pre-eclampsia, intrauterine growth
restriction and perinatal death.

 Identify and monitor those fetuses at risk of perinatal

mortality or morbidity due to uteroplacental insufficiency
 This is achieved by investigating blood volume flow to the
placenta; in the umbilical arteries and in the fetus.
 Assessment of the fetal circulation is essential in the better
understanding of the pathophysiology of a wide range of
pathological pregnancies and their clinical management
DOPPLER ULTRASOUND IN OBSTETRICS
USES OF DOPPLER IN OBSTETRICS

 Diagnosis of fetal hypoxia (acute or chronic)and acidosis in

pregnancy
 Prediction of fetal growth and maternal pathology
 For diagnosis of fetal discordance in multifetal pregnancy
 Diagnosing fetal anemia in Rh isoimmunisation
 Diagnosis of congenital anomalies and tumors
 Absolute velocities for precise fetal echocardiography
What Kind of Information on CD ?

 Utero placental circulation – Predictive

 Uterine Artery & Umbilical Artery
 Fetal Arterial Circulation – Cut Off Line
 Redistribution of Blood & brain Sparing Effect
 Fetal Venous Circulation - Decision
 Timing of Delivery
 Degree of acidemia & Hypoxia
DOPPLER ULTRASOUND IN OBSTETRICS

Changes due to Hypoxia

 When > 50% placenta is not functioning - Mild Hypoxia –

Umbilical artery
 When > 70% placenta not functioning - Moderate Hypoxia -
> Compensatory redistribution in MCA
 When > 90% placenta not functioning - Severe Hypoxia ->
Failure of Compensatory redistribution - DV
 Decrease uteroplacental perfusion
UTERINE ARTERY

Decrease fetal perfusion

UMBILICAL ARTERY

Fetal hypoxia and acidosis

MIDDLE CEREBRAL ARTERY
Redistribution of blood supply to vital organs

AORTIC ISTHMUS

Late compensatation of heart

Cardiac failure and fetal acidosis

DV,UMBILICAL VEIN

Fetal demise
 PLACENTA
Fetal heart
Mat. Heart
▼
▼
Umbilical
Ut. Arteries
arteries
▼
▼
Spiral art. Invaded by
Tertiary villous
trophoblast LOW PVR vessels
▼
▼
Uteroplacental circ Fetoplacental circ
FETAL CIRCULATION
Fetal circulation
 Antenatally, placenta is the sole source of oxygen
 O2 blood leaves placenta through umbilical vein, ductus
venosus, IVC to the fetal right atrium.
 From rt atrium blood is shunted across foramen ovale to lt
atrium and then to lt ventricle, aorta & fetal brain .
 Poorly oxygenated blood from SVC enters rt ventricle &
pulmonary artery
 Most of the blood is shunted through ductus arteriosus into
descending aorta
 Thus majority of blood enters systemic circulation rather
than pulmonary circulation as in adult
 Uteroplacental circulation

Uteroplacental vascular system Appearance of Doppler

with physiologic dilatation of frequency spectra recorded at
the spiral arteries different sites in the
uteroplacental vascular system.
Competent use of Doppler ultrasound techniques requires an
understanding of three key components:

(1) The capabilities and limitations of Doppler ultrasound;

(2) The different parameters which contribute to the flow

display;

(3) Blood flow in arteries and veins.

 DOPPLER ULTRASOUND
Doppler ultrasonography is a non-invasive procedure
that uses detectable changes in high frequency sound waves (2-
20 MHz), based on the Doppler effect, to create clear digital
images in real time.

Doppler ultrasonography is based on two basic principles:

1. Ultrasound principle:
• High-frequency sound wave aimed at a stationary target will
be reflected back and detected.
• The machine then displays the distances and intensities of
the echoes on the screen, forming a two dimensional image
2. Doppler principle
Ultrasound images of flow, whether color flow or spectral Doppler,
are essentially obtained from measurements of movement.
In ultrasound scanners, a series of pulses is transmitted to detect
movement of blood.
Echoes from stationary tissue are the same from pulse to pulse.
Echoes from moving target exhibit slight differences in the time
for the signal to be returned to the receiver .
It brings changes in the sound pitch depending on the movement
of the object ( blood) in relation to the detector (positive or negative
shift)- the speed of sound in blood is 1570 m/s)
These differences can be measured as a direct time
difference or, more usually, in terms of a phase shift from
which the ‘Doppler frequency’ is obtained (Figure 2).
They are then processed to produce either a color flow
display or a Doppler sonogram.
 T2 : time of returned signal

T1 : time of omitted signal T2

T1
pulse repetition frequency

(T2 –T1) time difference or phase shift with known beam / flow
angle can calculate flow velocity & also Doppler frequency is
obtained.
As time difference decrease the doppler frequency increase.
Ultrasound velocity measurement. The diagram shows a scatterer S moving at velocity
V with a beam/flow angle.
The velocity can be calculated by the difference in transmit-to-receive time from the
first pulse to the second (t2), as the scatterer moves through the beam.
 PRINCIPLES OF DOPPLER
SHIFT When the frequency of sound
emitted from a stationary
source is fixed, and its
insonation angle is known, the
Doppler shift (i.e. the difference
between the emitted and the
reflecting frequency) f D =
2f0v cosθ/c where
f D = Doppler shift,
f0 = frequency of the
transmitted beam,
v = velocity of sound within
:. the tissue,
θ = insonation angle &
c = speed of sound in tissue
Doppler frequency increase if:

• Blood flow velocity increased.

• Beam is more aligned to the direction of flow
(angle of insonation 0-15).
• higher transducer frequency is used.
Factors affecting doppler frequency 3

2
The angle of insonation
q
Flow velocity 1

(the angle q between the beam and the direction of

flow becomes smaller). This is of the utmost
importance in the use of Doppler ultrasound.
A: Higher-frequency Doppler signal (beam aligned to the direction of )
B: Less aligned than A and produces lower-frequency Doppler signal
C: The beam/flow angle is almost 90°and there is a very poor Doppler signal
D: The flow is away from the beam and there is a negative signal
 Aliasing
 If a second pulse is sent before the first is received, the
receiver cannot discriminate between the reflected signal
from both pulses and aliasing occur.

 So to eliminate aliasing, The pulse repetition frequency or

scale is set appropriately for the flow velocities
Waveform analysis of blood velocimetry
S = S/D ratio
D
S-D
= Resistance index
S

S-D
= Pulsatility index
S Vm (MEAN)

Doppler systolic-diastolic waveform

indices of blood flow velocity.
S = Systole ; D = Diastole
Vm Mean is calculated from computer
digitized waveform
D
 Waveform analysis of blood velocimetry
 These indices are relatively angle independent and are
therefore easily applied in clinical practice.
 In practice, none of the indices is superior to the other and
any index may be used.
 If end diastolic flow is absent, PI is the only index making
evaluation of blood flow possible, because in this situation
S/D will equal to infinite and RI to one.
 The PI is more complex because it requires the calculation
of the mean velocity, but modern Doppler sonographic
devices provide those values in real time
Vessels need to be examined
• Uterine artery
• Umbilical artery
• Middle cerebral artery
• Thoracic aorta
• IVC
• Ductus venosus
• Umbilical vein
MATERNAL
UTERINE
ARTERY
DOPPLER
 ANATOM
Y
 Ut. Artery is a branch of the int. iliac
a.
originating close to the iliac bifurcation
 The ut. arteries cross the ext. iliac a. on either side
to reach the uterus at the cervico-isthmic junction.
At this point it divides into the ascending &
descending branches.
 The ascending branch divides
into
arcuate, radial, spiral arteries.
 Indication of uterine artery Doppler
 Previous or present history of preeclampsia or any other
maternal disease like:
 Maternal collagen vascular disease
 Maternal hypertension
 DM with vasculopathy
 RPL – No work up or APL positive

 Previous child with IUGR

 Unexplained high maternal alpha fetoprotein level
 High HCG levels.
 Examination of the uterine
arteries
 Signal patterns are recorded from the main trunk of the
uterine artery on each side. The artery is located by
sweeping the transducer from medially to laterally into the
lower outer quadrant of the uterus.

 The uterine artery will appear as a red-encoded vessel

coursing toward the uterine fundus.

 The uterine artery and external iliac artery may appear to

cross paths, but this phenomenon is seen only during
pregnancy and results from increased uterine growth causing a
lateral shift of both uterine arteries.
Uterine artery
 Uterine artery
 To record uterine blood flow velocities. the sample
volume is placed on the uterine artery approximately
1-2 cm medial to the crossing site, and pulsed Doppler
is activated.

 Good-quality uterine artery spectra can be acquired at an

insonation angle of 15-50° and should present a sharp,
clear envelope curve.

 The optimum PRF setting for most examinations is

between 4 and 6 kHz, using a wall filter setting of 60-120
Hz.
 Uterine artery
 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).
Uterine artery
 NORMAL DOPPLER WAVEFORM
CHARACTERISTICS of uterine artery:
 At the start of pregnancy, the uterine signal pattern
shows high pulsatility with high systolic and low
diastolic flow velocities in addition to an early
diastolic (postsystolic) notch.

 This notch represents a pulse wave reflection due to

increased peripheral vascular resistance and is the
spectral counterpart of incomplete trophoblast
invasion.
 Uterine artery
 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 Under physiologic conditions,
the end- diastolic velocities increase with continued
gestation while vascular resistance decreases as
placentation progresses.
 So PI, RI and S/D ratio remain low.

 Diastolic notch gradually disappears & is not seen after

23-25 wks.
 Normal uterine artery waveforms

1- trimester Normal impedance to flow the

uterine arteries in 1º trimester

2 - trimester Normal impedance to flow the

uterine arteries in early 2ºtrimester

2-3 trimester Normal impedance to flow the

uterine arteries in late 2º and 3º
trimester
Doppler spectra recorded from the uterine artery at different
gestational ages. The progressive increase in diastolic flow
velocity is a result of normal trophoblast invasion
Normogram of Uterine artery
Doppler reference range for the
pulsatility index (PI) of the
uterine artery for a central
placental location.

• The 90% confidence interval

is shown.
• The upper curve represents
the approximate 95th
percentile.
95th percentile • the middle curve the 50th
percentile.
• and the lower curve the
50th percentile.
approximate 5th percentile
5th percentile
Resistance Index of the Uterine Artery Pulsatility Index of the Uterine Artery
Gestation BY PERCENTILE BY PERCENTILE
(weeks) 5th 50th 95th Gestation
18 0.222 0.447 0.659 (weeks) 5th 50th 95th
19 0.204 0.429 0.641 18 0.509 0.888 1.407
20 0.194 0.419 0.630 19 0.460 0.838 1.356
21 0.186 0.411 0.622 20 0.436 0.812 1.328
22 0.180 0.405 0.615
21 0.420 0.795 1.309
23 0.175 0.400 0.610
24 0.171 0.395 0.605 22 0.407 0.781 1.293
25 0.167 0.391 0.601 23 0.397 0.769 1.280
26 0.163 0.387 0.597 24 0.388 0.759 1.268
27 0.160 0.384 0.593 25 0.381 0.751 1.258
28 0.157 0.380 0.590 26 0.374 0.743 1.248
29 0.154 0.378 0.587
30 0.152 0.375 0.584 27 0.369 0.736 1.239
31 0.150 0.372 0.581 28 0.363 0.729 1.230
32 0.147 0.370 0.578 29 0.358 0.722 1.222
33 0.145 0.368 0.576 30 0.354 0.716 1.214
34 0.144 0.366 0.574 31 0.349 0.711 1.207
35 0.142 0.364 0.571
36 0.140 0.362 0.569 32 0.345 0.705 1.199
37 0.139 0.360 0.567 33 0.341 0.700 1.192
38 0.137 0.358 0.566 34 0.337 0.695 1.185
39 0.136 0.357 0.564 35 0.333 0.690 1.178
40 0.135 0.355 0.562 36 0.330 0.684 1.171
37 0.326 0.679 1.164
38 0.322 0.674 1.157
39 0.318 0.669 1.150
40 0.313 0.663 1.143
 Abnormal Uterine Artery Doppler
 Persistence of the diastolic notch (bilateral notch or unilateral
notch on placental side).
 Defective trophoblastic invasion leads to increase in RI, PI
values.
 Simultaneous presence of intrasystolic notch reflects an
extremely high impedance
 High vascular resistance (increased indices) i.e. RI > 0.58 after
23 wks ,PI > 1.45.
 RI or PI >95th centile
 Difference between right & left uterine artery S/D ratio > 1.0
 Uterine artery S/D > 2.6 after 22-24 wks scan.
 Important is normograph of PI of uterine artery. PI should go
down as the pregnancy advances.
 Uterine Artery [18-24 Weeks]
ABNORMAL
 Bilateral notch with mean RI >0.55
 Unilateral notch with mean RI >0.65
 Absence of notch with mean RI >0.70

 R.I.: >26 WKS : >0.58

 Doppler spectra of uterine artery flow.
Doppler shows high velocities
throughout the cardiac cycle,
indicating low distal
resistance.

normal uterine artery flow.

Doppler shows a pulsatile flow
waveform with low diastolic
velocities. This is indicative of high
distal resistance

Abnormal uterine artery flow.

Abnormal uteroplacental vascular system, with lack of
dilatation of the spiral arteries
 Effect of Uterine Contractions on Uterine
Artery Waveform
 The end-diastolic velocities in the uterine arteries are reduced
when the intrauterine pressure exceeds
 In the interval between contractions, there is a recovery or
normalization of uteroplacental blood flow with a
corresponding increase in end-diastolic velocities.
 Effect of medications on uterine
artery waveform
 Doppler provides a noninvasive method for the
evaluation of uteroplacental hemodynamics.
 One area of interest is the effect of vasoactive
medications on uterine blood flow.
 The following medications increases EDV and lower resistance
indices and hence improve uteroplacental circulation
• Betamimetics
• IV magnesium
• Alpha methyldopa and hydralazine
• Niphedipine
 Doppler Screening of Uterine
Vessels
 It is now understood that uterine artery doppler as a
screening test in low risk pregnancy has little or no value.
Its value is limited to high risk pregnancies.
 A positive uterine artery screening test
 Bilateral early diastolic notch
 S/D or PI  95th percentile
 A unilateral notch implies a relatively low risk of
pregnancy complications whereas a bilateral notch,
especially when combined with high RI values above the
95th Percentile
Uses of uterine artery doppler

 IN VITRO FERTILIZATION : If Ut A PI>3.26, very low chance of

achieving pregnancy, tells about receptivity of endometrium
for implantation

 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.
 Clinical Significance of Uterine
Doppler Ultrasound
Abnormal uterine blood flow velocities do correlate
well with
 existing or impending foetal growth
retardation
 preeclampsia, and
 increased rates of prematurity, placental
abruption , caesarean section, and low birth
weight
Flowchart for Doppler evaluation of the uterine
artery in high-risk patients.
 Treatment
 Aim - abnormal uterine artery Doppler in early
pregnancy can be effectively treated before onset
of pregnancy complications

 Treatment options
 Aspirin
 Vitamins C/E
 Low molecular weight heparin
Doppler study of
umbilical arteries
Uses of Umb artery doppler

plays a vital role in the diagnosis of fetal cardiac defects.

assessment of the hemodynamic responses to fetal
hypoxia and anemia.
diagnosis of other non-cardiac malformations.
 umbilical artery Anatomy
 Arise from the int. iliac a. of the fetus & course along the
umbilical cord in a long & winding path to reach the
placenta
 Intra placentally, they branch into the primary stem villous
arteries, which in turn branch into the secondary & tertiary
stem villous vessels
 The tertiary stem villi form the vascular bed of the
umbilical arteries
 As the preg. advances there is increase in the tertiary stem
villi & small muscular arteries leading to decrease in the pl.
vascular bed resistance
 umbilical artery Anatomy
 Arcuate Arteries: Run Circumferentially around the uterus.
 Uterus: Blood supply to anterior and posterior walls
provided by the Arcuate arteries.
 Radial Arteries: Extend from the arcuate arteries and enter
the endometrium.
 Spiral Arteries: connect the maternal circulation to the
endometrium.
 Responsible for a 10 fold increase in blood flow
 umbilical artery Anatomy

small muscular spiral arteries large vascular channels

Conversion of small muscular spiral arteries into large

vascular channels transforms the uteroplacental circulation
into a low-resistance-to-flow system. These have a dilated
and tortuous lumen, a complete absence of muscular and
elastic tissue, no continuous endothelial lining.
 umbilical artery
Technique of imaging umbilical artery
 In practice, the UA is best examined in a segment of free
floating umbilical cord.
 In case of fetal movement placental insertion is preferred
site for measurement.

 Waveforms obtained from the placental end of the cord show

more end-diastolic flow, thus lower ratio values (RI,S/D)
than waveforms obtained from the abdominal cord insertion.
The difference is minimal with no clinical significance.
(higher at the abdominal wall than the insertion.)
 If there is reversed flow, the umbilical artery is re-examined
close to placental insertion as this segment of the artery is
the last to develop reversed flow.
 umbilical artery
• 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
 umbilical artery
 Benefit of Umbilical Artery Evaluation Less experienced
operators can achieve
 highly reproducible results with simple, inexpensive
continuous-wave equipment

 The 40% of the combined fetal ventricular output is

directed to the placenta by two umbilical arteries. The
assessment of umbilical blood flow provides information on
blood perfusion of the fetoplacental unit .
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
 Normal umbilical artery waveforms:
 Early weeks of gestation (till 12 wks)- absent End diastolic
blood flow
 Between 12 to 14 wks –End diastolic flow develops
 Beyond 14 weeks: end diastolic flow progressively
increases.
 As pregnancy advances, there is increase in the diastolic
flow & the RI is low
 Umbilical artery sampling is not done in early preg.
 UMBILICAL ARTERY normal
FLOW
Characteristic saw-tooth appearance of arterial flow
in one direction and continuous umbilical venous
blood flow in the other.

Color Doppler image of normal free

loop of umbilical cord,
demonstrating the two arteries (red)
and one vein (blue) at 28 weeks
Normal color Doppler frequency spectrum sampled
from the umbilical artery
 Normal Umbilical Artery Doppler
indices
With advancing gestation, umbilical arterial Doppler waveforms
demonstrate a progressive rise in the end-diastolic velocity and a decrease
in the pulsatility index.

• 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 <3 to 3.5

Reference Values for Serial Measurements of the Umbilical Artery
Systolic-Diastolic Ratio
(S/D) SYSTOLIC-DIASTOLIC RATIO, BY PERCENTILE
Gestation
2.5th 5th 10th 25th 50th 75th 90th 95th 97.5th
(weeks)
19 2.73 2.93 3.19 3.67 4.28 5.00 5.75 6.26 6.73
20 2.63 2.83 3.07 3.53 4.11 4.80 5.51 5.99 4.43
21 2.51 2.70 2.93 3.36 3.91 4.55 5.22 5.67 6.09
22 2.43 2.60 2.83 3.24 3.77 4.38 5.03 5.45 5.85
23 2.34 2.51 2.72 3.11 3.62 4.21 4.82 5.22 5.61
24 2.25 2.41 2.62 2.99 3.48 4.04 4.63 5.02 5.38
25 2.17 2.33 2.52 2.88 3.35 3.89 4.45 4.83 5.18
26 2.09 2.24 2.43 2.78 3.23 3.75 4.30 4.66 5.00
27 2.02 2.17 2.35 2.69 3.12 3.63 4.15 4.50 4.83
28 1.95 2.09 2.27 2.60 3.02 3.51 4.02 4.36 4.67
29 1.89 2.03 2.20 2.52 2.92 3.40 3.89 4.22 4.53
30 1.83 1.96 2.13 2.44 2.83 3.30 3.78 4.10 4.40
31 1.77 1.90 2.06 2.36 2.75 3.20 3.67 3.98 4.27
32 1.71 1.84 2.00 2.29 2.67 3.11 3.57 3.87 4.16
33 1.66 1.79 1.94 2.23 2.60 3.03 3.48 3.77 4.06
34 1.61 1.73 1.88 2.16 2.53 2.95 3.39 3.68 3.96
35 1.57 1.68 1.83 2.11 2.46 2.87 3.30 3.59 3.86
36 1.52 1.64 1.78 2.05 2.40 2.80 3.23 3.51 3.78
37 1.48 1.59 1.73 2.00 2.34 2.74 3.15 3.43 3.69
38 1.44 1.55 1.69 1.95 2.28 2.67 3.08 3.36 3.62
39 1.40 1.51 1.64 1.90 2.23 2.61 3.02 3.29 3.54
40 1.36 1.47 1.60 1.85 2.18 2.56 1.96 3.22 3.48
41 1.33 1.43 1.56 1.81 2.13 2.50 2.90 3.16 3.41
Resistance Index of the Umbilical Artery Pulsatility Index of the Umbilical Artery
Between 20 and 40 Weeks of Gestation Between 20 and 40 Weeks of Gestation
RESISTANCE INDEX (RI), PULSATILITY INDEX (PI),
Gestation BY PERCENTILE Gestation BY PERCENTILE
(weeks) 5th 50th 95th (weeks) 5th 50th 95th
20 0.567 0.690 0.802 20 0.940 1.216 1.505
21 0.557 0.680 0.793 21 0.913 1.189 1.476
22 0.548 0.671 0.784 22 0.890 1.165 1.450
23 0.539 0.663 0.776 23 0.869 1.142 1.427
24 0.530 0.655 0.768 24 0.849 1.122 1.405
25 0.522 0.646 0.760 25 0.831 1.102 1.385
26 0.514 0.639 0.752 26 0.813 1.084 1.365
27 0.506 0.631 0.745 27 0.798 1.065 1.346
28 0.498 0.623 0.737 28 0.780 1.048 1.327
29 0.490 0.615 0.730 29 0.764 1.031 1.308
30 0.482 0.608 0.723 30 0.748 1.014 1.290
31 0.474 0.600 0.715 31 0.732 0.997 1.272
32 0.465 0.592 0.707 32 0.716 0.980 1.254
33 0.457 0.584 0.700 33 0.700 0.963 1.236
34 0.449 0.576 0.692 34 0.684 0.946 1.218
35 0.440 0.567 0.684 35 0.668 0.928 1.199
36 0.431 0.559 0.675 36 0.651 0.910 1.180
37 0.422 0.550 0.667 37 0.634 0.891 1.160
38 0.412 0.540 0.657 38 0.615 0.872 1.139
39 0.402 0.530 0.648 39 0.595 0.851 1.117
40 0.390 0.519 0.637 40 0.573 0.828 1.093
 TABLE 22-5 Reference Values for Umbilical Artery (UA) and Middle Cerebral
Artery (MCA) Resistance Indices, as Well as Their Ratio, by Percentile
UA RESISTANCE INDEX MCA RESISTANCE MCA/UA R.I. RATIO
Gestation
(weeks) 5th 50th 95th 5th 50th 95th 5th 50th 95th

24 0.615 0.717 0.828 0.778 0.867 – 0.696 0.809 0.968

25 0.605 0.707 0.819 0.789 0.881 – 0.676 0.791 0.955
26 0.594 0.697 0.810 0.795 0.892 – 0.658 0.775 0.945
27 0.583 0.687 0.802 0.798 0.898 – 0.642 0.761 0.937
28 0.572 0.678 0.793 0.797 0.901 – 0.628 0.750 0.932
29 0.562 0.668 0.785 0.793 0.900 – 0.616 0.740 0.929
30 0.551 0.658 0.776 0.786 0.897 – 0.606 0.732 0.928
31 0.540 0.648 0.767 0.776 0.891 – 0.597 0.726 0.929
32 0.530 0.638 0.759 0.764 0.883 – 0.590 0.722 0.931
33 0.519 0.629 0.750 0.750 0.872 – 0.585 0.719 0.936
34 0.508 0.619 0.742 0.734 0.860 – 0.581 0.717 0.941
35 0.498 0.609 0.733 0.717 0.846 – 0.578 0.717 0.949
36 0.487 0.599 0.724 0.698 0.831 – 0.576 0.718 0.957
37 0.476 0.589 0.716 0.677 0.814 – 0.575 0.720 0.967
38 0.465 0.580 0.707 0.655 0.795 – 0.576 0.724 0.978
39 0.455 0.570 0.699 0.632 0.776 – 0.577 0.728 0.991
40 0.444 0.560 0.690 0.607 0.755 – 0.580 0.734 1.004
41 0.433 0.550 0.681 0.582 0.734 – 0.583 0.740 1.018
42 0.423 0.540 0.673 0.556 0.711 – 0.588 0.747 1.034
FACTORS AFFECTING UMBILICAL ARTERY
DOPPLER FLOW VELOCITY WAVEFORMS*
 UMBILICAL ARTERY
Abnormal umbilical a. waveform:

1. Low diastolic flow [ High resistance ] i.e resistance indices

above the 95th percentile
2. AEDF - Absent End Diastolic Flow
3. REDF - Reverse End Diastolic Flow
Above 3 types are an indication of increasing resistance which
correlates with FETAL HYPOXIA.
 UMBILICAL ARTERY
Abnormal umbilical a. waveform:
 Occlusion of the tertiary villous arteries due to thrombosis,
fibrinoid necrosis or edema
 Decreased no. of small muscular arteries lead to
asymmetric IUGR

 Why umbilical a. doppler can’t be used as a “screening test”

for IUGR?
Upto 70% of the placental tertiary villi should be affected
to show changes in umbilical a. waveform, while even
when 40% of the villi are affected, IUGR will be present.
 UMBILICAL ARTERY
• 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
 UMBILICAL ARTERY
Abnormal Umbilical Artery Doppler

 Umbilical artery Rl 0.8 is always abnormal at any

gestational age.
 PI valves range from 2.0 to 1.5 in second trimester and 1.5
to 1.0 in third trimester. Values above this is abnormal.
 S/D ratio > 3 in umbilical a. beyond 30 weeks is abnormal.
 Absent End Diastolic Flow (AEDF)
This implies increased
placental vascular resistance.

Reversal of Diastolic Flow (ROEDF)

This implies that placental

resistance is so high that blood
flows away from the placenta
back into the umbilical arteries
during diastole.
 Progression of
Abnormal Doppler BAD
Waveform of
Umbilical Artery
Decreased diastolic flow

VERY BAD

Absent diastolic flow

AWFU
Normal diastolic flow L

Reverse flow
 UMBILICAL ARTERY
 UA doppler is the “tip of iceberg “with respect
to fetal hemodynamic state
 Doppler shouldn’t 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
 UMBILICAL ARTERY

SOGC guidelines for Umbilical artery Doppler:

1. Should not be used as a screening tool in low-risk women

2. Should be performed in suspected IUGR or placental
pathology (preeclampsia)
3. Abnormal Doppler is an indication for increased fetal
surveillance or delivery, depending on other clinical factors
 UMBILICAL ARTERY
Pitfalls:
 Fetal movements & Fetal breathing movements will induce
high beat to beat variability.
 Common sources of error are too-low insonation angle,
wall filter setting > 120 Hz, poorly defined Doppler
waveform, or a heart rate outside normal limits
 Transient AEDF may be due to cord compression or due to
myo-metrial contraction
 Changing patient’s position or examination after sometime
can show a normal doppler waveform
 UMBILICAL ARTERY

Pulsed Doppler ultrasound shows dramatic variations (arrows) in UA peak systolic

velocity during fetal breathing.

Umbilical vein flow (open arrow) is also phasic. The tracing was normal after
breathing stopped.
 UMBILICAL ARTERY
Artefactual loss of end-diastolic frequencies

 A high angle between the ultrasound beam and the vessel

results in very low frequencies disappearing below the height
of the vessel wall filter
 If end-diastolic frequencies appear absent you should reduce
the vessel wall filter to its lowest setting, or remove it if
possible.
 Then you should alter the angle of the probe relative to the
maternal abdomen to reduce the angle of insonation.
 If end diastolic frequencies are still absent you should then
attempt to obtain the signal from a different site, because this
is likely to result in a different angle of insonation.
 Do not report the absence of end-diastolic frequencies until
this has been demonstrated on two successive days.
 UMBILICAL ARTERY
 It is important to note that normal umbilical artery
waveforms after 34 weeks’ gestation do not exclude fetal
hypoxemia and acidemia.
 Loss of end-diastolic frequencies occurs only when over
70% of the placental vascular bed has been obliterated.
 The latter is less likely to occur after 34 weeks’ gestation,
hence the limitation of umbilical artery Doppler at later
gestations
 UMBILICAL ARTERY
Treatment
 > 32-34 weeks
Abnormal Doppler contributes to decision to deliver
 In second trimester
Weigh risks of hostile intrauterine environment vs risks of
extreme prematurity
 AEDF
Bed rest, aggressive management of maternal disease
30% improve within 48 hrs
Improvement supports continuation of pregnancy in
second trimester
Perinatal mortality AEDF:9%
 Single Umbilical Artery
 Absence of the left umbilical
artery (73%) is more common
than the right (27%).
 Due to the markedly increased
rate of congenital anomalies,
chromosomal abnormalities.
intrauterine growth
retardation,prematurity, and
increased perinatal mortality,
the affected fetuses are
considered high-risk and should
undergo a detailed ultrasound
evaluation
 Color imaging of the fetal pelvic vessels can also be a
useful adjunct.
 In Doppler studies of the common iliac arteries and
femoral arteries, significantly higher pulsatility indices
have been found on the side of the absent umbilical
artery i.e., the side that does not contribute to the
fetoplacental circulation.
 Single umbilical artery is associated with:

• Usually normal with isolated SUA

• 50% aneuploidy rate if SUA + other anomalies
• Trisomy 18
• Trisomy 13
• Sirenomyelia
• Renal agenesis
Middle Cerebral Artery (MCA)
• Main branch of circle of Willis
• Carries 80% of blood supply
• 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
• Easy to repeat
 Imaging technique of MCA
Obtain an axial section of the head at the level of sphenoid bone.
Use color Doppler to identify circle of Willis.

"Zoom" image to see entire length MCA

 Place cursor close to origin 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) or proximal third portion of the vessel, have shown the best
reproducibility
 Angle of insonation should be zero (0)
Do not use angle correction

Take several measurements (at least three) with 15-30 waveforms

 Velocities should be similar

 Take best measurement
 Do not average several velocities
Avoid sampling during periods of fetal breathing and increased activity.
Average of both MCAs must be calculated for more precise result.
 The middle cerebral artery is most easily visualized
in a transverse plane. First the fetal head is imaged in the
standard biometry plane, and then the plane is shifted
downward toward the skull base at the level of sphenoid
bone. This brings into view the circle of Willis.

The best site for recording a Doppler spectrum is

approximately 2 mm from the circle of Willis or at the origin
of the internal carotid artery.
 Axial color Doppler ultrasound shows correct technique
for sampling the MCA. There must be no angle between
the long axis of the vessel (curved arrow) and the
ultrasound beam (open arrows).
 MCA-
PD

Doppler angle should be between 0-20 degree

Measure peak systole & end diastole & indices are calculated
Normal MCA waveforms

Circle of willis

Normal impedance to flow in first

trimester

Normal impedance to flow in second

trimester
 Middle cerebral artery

The blood velocity increases with advancing gestation,

and this increase is significantly associated with the
decrease in PI
Reference Values for the Resistance Index of the
Middle Cerebral Artery
RESISTANCE INDEX, RESISTANCE INDEX,
Gestation BY PERCENTILE Gestation BY PERCENTILE
(weeks) 5th 50th 95th (weeks) 5th 50th 95th
18 0.544 0.687 0.787 31 0.652 0.798 0.907
19 0.574 0.708 0.808 32 0.645 0.792 0.902
20 0.592 0.727 0.828 33 0.636 0.783 0.894
21 0.608 0.744 0.846 34 0.625 0.773 0.885
22 0.622 0.758 0.861 35 0.612 0.761 0.873
23 0.633 0.771 0.874 36 0.597 0.747 0.86
24 0.643 0.782 0.886 37 0.579 0.73 0.844
25 0.651 0.79 0.895 38 0.56 0.712 0.826
26 0.656 0.796 0.902 39 0.539 0.692 0.807
27 0.659 0.801 0.907 40 0.515 0.669 0.785
28 0.661 0.803 0.91 41 0.489 0.644 0.761
29 0.66 0.803 0.911 42 0.462 0.618 0.735
30 0.657 0.801 0.91
 Middle cerebral artery

 Unlike the uterine & umbilical artery vascular beds

which constantly change with advancing gestational
age, the MCA vascular bed resistance is almost
constant throughout pregnancy.
RI= 0.75-0.85
 MCA is more sensitive to hypoxia than umbilical
artery.
 MCA response to fetal hypoxia is instant.
 High systole in MCA → fetal anemia
 High diastole in MCA → brain sparing effect in fetal
hypoxia
 Middle cerebral artery

CEREBROPLACENTAL RATIO:
 In normal fetus, the placental vascular resistance
decreases as pregnancy advances, whereas the
MCA resistance is almost constant (S/D ratio of
MCA should be >S/D ratio of UA throughout
gestation)

 RI MCA/RI UMB > 1

 Cerebral distribution: MCA RI decreases & UMB RI
increases lead to CPR < 1, indicating fetal hypoxia
 Middle cerebral artery

 In IUGR /hypoxia - leads to activation of autoregulatory fetal

compensatory mechanisms cause constriction of the
splanchnic, renal & pulmonary vascular beds with
redistribution of 70% arterial blood flow to the cerebrum,
myocardium, adrenals.

 This is reflected in the MCA as increased diastolic flow with

reduced RI. (brain sparing effect in fetal hypoxia)

 i.e autoregulation in fetal circulation causing increased flow

towards brain, heart and adrenals and decreased towards
kidney, placenta and peripheries.
 Middle cerebral artery
 The cerebral arteries tend to become dilated in order to preserve the
blood flow to the brain and the systolic to diastolic (S/D) ratio will
decrease (due to an increase in diastolic flow)

 Autoregulation leads to;

 Increase in peak systolic velocity (PSV)

 Diastolic flow increases - D

 Decrease in MCA S/D ratio, PI,RI ,values

 UA SD ratio increases as placental resistance increases.

 Reversal of S/D ratio (UA>MCA) in IUGR is called “head sparing”

or “brain sparing" pattern
 Brain sparing effect

Normal

Fetal adaptation / response to hypoxemia

BRAIN, heart, adrenals

Vasodilatation
 Abnormal frequency spectrum recorded from the MCA with
color Doppler in a fetus with severe intrauterine growth
retardation at 27 weeks. This waveform pattern, called the
brain-sparing effect, is characterized by increased end-diastolic
flow velocities.
 Middle cerebral artery
 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 delivery or fetal demise.
 Simultaneous improvement of UA tracing towards normal
is better indicator.
 Pulsed Doppler ultrasound shows abnormal low resistance
flow in the MCA in a fetus with growth restriction. The SD ratio
of 2.19 was less than that of the UA. Note the prominent
antegrade diastolic flow (arrows).
Reversal in MCA : cerebral edema
 Role of MCA doppler in evaluation
of fetal anemia
 This concept is based on animal data indicating
that fetal blood velocities become elevated in
response to an increase in cardiac output and a
decline in blood viscosity when the fetus
becomes anemic.

 Mari and coworkers are credited with the first

description of using the peak systolic velocity in
the middle cerebral artery to detect fetal
anemia.
 Role of MCA doppler in evaluation
of fetal anemia
 Because the normal peak systolic velocity in this
vessel increases with advancing gestational age,
the value in cm/s must be converted to multiples
of the median (MoMs).
 MCA velocity of > 1.50 MoMs detected all cases
of moderate to severe anemia.

 MCA doppler velocimetry was determined to be

more accurate than amniocentesis in detecting
severe fetal anemia.
 Fetal MCA velocity determinations can be initiated as
early as 18 weeks' gestation once the fetus is at risk for the
development of anemia. Doppler studies are repeated
every 1 to 2 weeks based on the trend in the data
 Middle cerebral artery
in Fetal Anemia: increased velocity

Angle=0°
 Vmax >1.5 MoM
 Se=100% Indications: maternal antibodies,
NPV=100% fetal hydrops, parvovirus exposure,
 FP=12% etc…
 PPV=65%
TABLE 22-6 Threshold of Peak Velocity of Systolic Blood Flow in
the Middle Cerebral Artery Above Which Mild, Moderate, and
Severe Anemia Occur
PEAK VELOCITY THRESHOLD (cm/sec)
Gestation
(weeks) Severe Moderate Mild
Anemia Anemia Anemia
18 29.9 34.8 36.0
20 32.8 38.2 39.5
22 36.0 41.9 43.3
24 39.5 46.0 47.5
26 43.3 50.4 52.1
28 47.6 55.4 57.2
30 52.2 60.7 62.8
32 57.3 66.6 68.9
34 62.9 73.1 75.6
36 69.0 80.2 82.9
38 75.7 88.0 91.0
40 83.0 96.6 99.8
 Hyperactivity of fetus, increase of intrauterine pressure
(polyhydramnios), and external pressure to the fetal head
(e.g. by the probe) might erroneously increase end diastolic
flow velocities
Role of Doppler in management of placental insufficiency

 I. Prediction IUGR/preeclampsia (long term)

• Uterine arteries (notch/increased resistance)
• Objective : population screening / IUGR etiology

 II. Diagnosis/surveillance (mid term)

• Umbilical arteries
• Objective : adjust frequency of monitoring

 III. Fetal well-being (short term)

• Umbilical arteries
• Cerebral arteries http://www.fetalmedicine.com/
fmf/online-education/03-doppler/
• Other fetal Dopplers
• Ductus Venosus, IVC
• Aortic isthmus etc…
• Objective : decide when to deliver a fetus with IUGR
ADVANTAGE OF DOPPLER OBS VS BPP

 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 unnecessary
invasive procedures.
Thank u
THORACIC AORTA DOPPLER
FETAL
AORTA
 FETAL AORTA
Comment
 Acidosis causes peripheral arterial spasm & rises PI of
femoral arteries, consequently increases thoracic aorta PI.
 If fetal 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.
 FETAL AORTA
 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.
 It’s 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

 Ductus venosus DOPPLER
 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 .
Ductus venosus

Ductus venosus flow reflects the

cardiac response (right atrium)
to hypoxia
Ductus venosus DOPPLER

Normal

Abnormal

Critical
Ductus Venosus Peak Velocity Index: (S − a)/D Ductus Venosus Preload Index: a/S
Gestation PEAK VELOCITY INDEX, BY PERCENTILE Gestation PRELOAD INDEX, BY PERCENTILE
(weeks) 5th 50th 95th (weeks) 5th 50th 95th
20 0.381 0.580 0.779 20 0.342 0.508 0.674
21 0.380 0.579 0.779 21 0.341 0.507 0.673
22 0.380 0.579 0.778 22 0.341 0.507 0.673
23 0.379 0.578 0.777 23 0.340 0.506 0.672
24 0.678 0.578 0.777 24 0.339 0.505 0.671
25 0.378 0.577 0.776 25 0.339 0.505 0.671
26 0.377 0.576 0.776 26 0.338 0.504 0.670
27 0.338 0.504 0.670
27 0.377 0.576 0.775
28 0.337 0.503 0.669
28 0.376 0.575 0.774
29 0.336 0.502 0.668
29 0.375 0.575 0.774 30 0.336 0.502 0.668
30 0.375 0.574 0.773 31 0.335 0.501 0.667
31 0.374 0.573 0.773 32 0.335 0.501 0.667
32 0.374 0.573 0.772 33 0.334 0.500 0.666
33 0.373 0.572 0.771 34 0.333 0.499 0.665
34 0.372 0.572 0.771 35 0.333 0.499 0.665
35 0.372 0.571 0.770 36 0.332 0.498 0.664
36 0.371 0.570 0.770 37 0.332 0.498 0.664
37 0.371 0.570 0.769 38 0.331 0.497 0.663
38 0.370 0.569 0.768 39 0.330 0.496 0.662
39 0.369 0.569 0.768 40 0.330 0.496 0.662
40 0.369 0.568 0.767
TABLE 22-11 Ductus Venosus Pulsatility TABLE 22-12 Ductus Venosus S/a Ratio
Index: (S − a)/TAMX Gestation S/a RATIO, BY PERCENTILE
PULSATILITY INDEX, (weeks) 5th 50th 95th
Gestation BY PERCENTILE 20 1.331 2.161 2.991
(weeks) 5th 50th 95th 21 1.329 2.159 2.989
20 0.410 0.643 0.875 22 1.327 2.157 2.987
21 0.409 0.642 0.874 23 1.324 2.154 2.984
22 0.408 0.641 0.873 24 1.322 2.152 2.982
23 0.407 0.640 0.872 25 1.320 2.150 2.980
24 0.406 0.639 0.871 26 1.318 2.148 2.978
25 0.405 0.638 0.870
27 1.315 2.145 2.975
28 1.313 2.143 2.973
26 0.404 0.637 0.869
29 1.311 2.141 2.971
27 0.403 0.636 0.868
30 1.308 2.138 2.968
28 0.402 0.635 0.867
31 1.306 2.136 2.966
29 0.401 0.634 0.866 32 1.304 2.134 2.964
30 0.400 0.633 0.865 33 1.301 2.131 2.961
31 0.399 0.632 0.864 34 1.299 2.129 2.959
32 0.398 0.631 0.863 35 1.297 2.127 2.957
33 0.397 0.630 0.862 36 1.295 2.125 2.955
34 0.396 0.629 0.861 37 1.292 2.122 2.952
35 0.395 0.628 0.860 38 1.290 2.120 2.950
36 0.394 0.627 0.859 39 1.288 2.118 2.948
37 0.393 0.626 0.858 40 1.285 2.115 2.945
38 0.392 0.625 0.857
39 0.391 0.624 0.856
40 0.390 0.623 0.855
Ductus venosus DOPPLER
Ductus venosus DOPPLER
 Ductus venosus DOPPLER

DV waveforms showing reversal of ‘a’ wave

 Ductus venosus DOPPLER
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
 Umbilical vein shows monophasic , continuous non
pulsatile flow after first trimester in uncomplicated
pregnancy.
 It shows 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.
 Umbilical Vein Blood Flow MEAN VELOCITY (cm/sec)
Gestation BY PERCENTILE Gestation BY PERCENTILE
(weeks) 5th 50th 95th (weeks) 5th 50th 95th
20 5.70 7.90 10.70 31 7.04 9.67 13.02
21 5.82 8.06 10.91 32 7.17 9.83 13.23
22 5.94 8.22 11.12 33 7.29 9.99 13.44
23 6.07 8.38 11.33 34 7.41 10.16 13.66
24 6.19 8.54 11.54 35 7.53 10.32 13.87
25 6.31 8.71 11.76 36 7.65 10.48 14.08
26 6.43 8.87 11.97 37 7.78 10.64 14.29
27 6.56 9.03 12.18 38 7.90 10.80 14.50
28 6.68 9.19 12.39 39 8.02 10.96 14.71
29 6.80 9.35 12.60 40 8.14 11.12 14.92
30 6.92 9.51 12.81
IVC DOPPLER
IVC DOPPLER
 IVC DOPPLER
COMPARISON
NORMAL PATTERN ABNORMAL PATTERN
IVC shows triphasic pulsatile In IUGR fetuses the IVC shows
waveforms increase in reversed flow
➢ first forward wave during during atrial contraction
ventricular systole

➢ 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
• Chronic maternal diseases such as nephropathy, autoimmune
disease, coagulation disorders, diabetes and hypertension
 FETAL ANOMALIES
 EFFECT OF DRUGS
Doppler used to asses;
 Changes in ductus
 Vein of galen
arteriosus doppler after
malformation use of indomethacin for
 Renal agenesis preterm labour and
 Sacrococcygeal teratoma polyhydramnios(with
increasing severity)
 Sequestration of lung
 raised PSV
 Congenital diapharamatic
 raised EDV
hernia
 Assesment of a two or  features of TR
three vessel umbilical cord
VEIN OF GALEN ANEURYSM
RENAL AGENESIS
Unilateral renal agenesis with
MCDK
 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 contraindicated
3 FOLD NUCHAL
CORD
 TABLE 22-14 Mitral and Tricuspid Valve E/A Ratios
MITRAL VALVE E/A TRICUSPID VALVE
Gestation E/A RATIO, BY PERCENTILE
RATIO, BY PERCENTILE
(weeks)
2.5th 50th 97.5th 2.5th 50th 97.5th
20 0.40 0.59 0.77 0.47 0.65 0.83
21 0.42 0.60 0.79 0.49 0.66 0.84
22 0.43 0.62 0.80 0.50 0.68 0.85
23 0.45 0.63 0.82 0.52 0.69 0.86
24 0.46 0.65 0.83 0.53 0.70 0.87
25 0.48 0.66 0.84 0.54 0.71 0.88
26 0.49 0.68 0.86 0.55 0.72 0.89
27 0.50 0.69 0.87 0.56 0.73 0.90
28 0.52 0.70 0.88 0.57 0.74 0.90
29 0.53 0.71 0.89 0.58 0.74 0.91
30 0.54 0.73 0.90 0.58 0.75 0.91
31 0.55 0.74 0.91 0.59 0.75 0.92
32 0.56 0.75 0.92 0.59 0.76 0.92
33 0.57 0.76 0.93 0.60 0.76 0.92
34 0.58 0.76 0.93 0.60 0.76 0.92
35 0.59 0.77 0.94 0.60 0.76 0.92
36 0.59 0.78 0.95 0.60 0.76 0.92
37 0.60 0.79 0.95 0.60 0.76 0.92
38 0.61 0.79 0.96 0.60 0.76 0.92
 TABLE 22-15 Peak or Maximum Velocity of the Aorta and Main Pulmonary Artery
AORTA PEAK VELOCITY (cm/sec), PULMONARY ARTERY PEAK VELOCITY
BY PERCENTILE (cm/sec), BY PERCENTILE
Gestation
2.5th 50th 97.5th 2.5th 50th 97.5th
(weeks)
20 29 62 95 23 53 80
21 30 63 96 24 54 81
22 32 65 98 25 56 82
23 33 66 99 27 57 84
24 34 67 100 28 58 85
25 36 68 101 29 59 86
26 37 70 103 30 61 87
27 38 71 104 31 62 89
28 40 72 105 32 63 90
29 41 74 107 34 64 91
30 42 75 108 35 65 92
31 44 76 109 36 67 93
32 45 77 110 37 68 95
33 46 79 112 38 69 96
34 48 80 113 39 70 97
35 49 81 114 41 72 98
36 50 82 115 42 73 100
37 52 84 117 43 74 101
38 53 85 118 44 78 102
FETAL VENOUS DOPPLER
 DUCTUS VENOSUS
 IVC
 HEPATIC VEIN
 UMBILICAL VEIN
DV DOPPLER IDENTIFY WHAT
IS
HAPPENING IN THE HEART
 Of all the precardial veins, the ductus venosus
yields the best and most reliable information on
fetal myocardial hemodynamics and cardiac
function while providing reproducible spectra.

 DV transports oxygenated blood from umbilical

vein to the right atrium & ventricle,then to
myocardium & brain.

 DV doppler reflects right ventricular preload.

 ANATOMY
:
 Trumpet shape
 Arises from transverse portion of left Portal
vein or umbilical sinus & connected to IVC
 Funnel shape, length 2 cm, ≤ 2mm wide
 It has muscular coat & sphyncteric action
 Direction: caudocranial, ventrodorsal
 45% of blood from the umbilical vein
via IVC through the DV, bypassing the
liver
 Best image of DV in
dorsoposterior position
 Three-dimensional B flow image from a 17-week-
old fetus illustrating the relationships of the venous
system, heart and aorta.
 DV is identified in the trasverse [at the level of the portal
vein ] or sagittal section of fetal abd.
 The intrahepatic segment of the umbilical vein should be
imaged first to gain rapid venous orientation.
 The vein is optimally visualized either in the midsagittal
plane or in an oblique transverse scan through the fetal
abdomen.
 The intrahepatic segment of the umbilical vein points to
the site where the vein enters the ductus venosus.
 Following left portal vein as a ’c’ curve in liver , will
bring the DV into view.
 Color Doppler ultrasound of a coronal plane of the fetal
abdomen and chest showing the inferior vena cava (IVC).
joined by the ductus venosus (DV) and the left hepatic vein
(LHV) as it enters the right atrium (RA).
DV
 How to sample DV?
 To record flow signals. the sample volume is positioned
directly at the junction of the umbilical vein with the
ductus venosus.
 The width of the sample volume (approximately 2.5-6
mm) should just span the vessel; otherwise it would
detect unwanted signals from the closely adjacent
hepatic veins and umbilical vein.
 The use of color Doppler makes it considerably easier to
locate the ductus venosus and accurately position the
sample volume.
 The color-flow image will clearly reveal the difference in
flow velocity between the umbilical vein and ductus
venosus. The 3-4 times higher blood flow velocity in the
ductus venosus leads to a color reversal with aliasing.
 The spectrum is always sampled at the
origin of the ductus venosus,which is the
site where the color reversal occurs .
 An insonation angle less than 30° (or 50°)
is recommended to obtain an optimum
waveform.
 The wall filter should be set as low as
possible-between 125Hz and 50 Hz
depending on the instrument.
Ductus venosus
 DV SPECTRAL
WF:
 ‘M’ Pattern
 High velocity , turbulent, forward
flow, envelop never reaches
baseline
 HV/IVC

DV

AV VALVE

HIGHEST PRESSURE GRADIENT BETWEEN THE VENOUS

VESSELS & THE RA OCCURS DURING VEN. SYSTOLE -
HIGHEST FORWARD FLOW
VENTRICLES CONTRACT- AV RING PUULED DOWN-
ATRIA
DILATE- FORWARD FLOW
 HV/IVC

DV

AV VALVE

AV FLAPS OPEN – BLOOD GOES FROM A

TO V- 2nd FORWARD FLOW
 HV/
IVC

DV

AV VALVE

PASSIVE FILLING OF VENTRICLES DURING

ATRIAL CONTRACTION – FORWARD FLOW
Normal ductus venosus spectra as a function of gestational age. With
advancing gestational age, the absolute flow velocity increases while
pulsatility declines.
 DV – imp. event, forward flow
during atrial contraction

 DV is close to heart- it reflects events of rt.

atrium
 RA enlarges- ostia of IVC enlarges- RA is
full of blood, RA pressure increases than
DV pressure – only small amt. of blood
goes to RV during atria systole & through
IVC blood goes back to DV [reversal of ‘A’
wave]
 ABNORMAL DV
WF
 Normal RV- ventricular muscle- elastic
,
easily distensible, thin -here narrow DV
 Decreased RV compliance
 Decreased preload – abnormal DV flow
 Myocardium becomes non elastic,
compliance decreases, RA has to work
hard
 Here DV – wide: reversal of blood flow into
Doppler frequency spectra of the ductus venosus show
increasing pathology (a-d) as a result of myocardial
insufficiency.
S/A index of DV waveform
 Ductus venosus (DV) Doppler waveforms show
2 periods of decreased velocity during
isovolumetric relaxation (isovolumetric relaxation
velocity [IRV]) and atrial contraction (A wave or
end-diastolic velocity [EDV]).

 The S-wave/isovolumetric A-wave (S/A index)

for each fetus was compared to
fetal/neonatal outcomes.
(S/A) index = PSV/(IRV + EDV)

Flow velocity waveforms of the
 DV in an IUGR fetus at
13 days (A),
7 days (B),
48 hours (C) before
intrauterine
death at 25 weeks’
gestation
 ABNORMAL
DV
 SICK FETUS– IUGR ,FETAL →cardiac
ANEMIA
 decompensation
1st TRIMESTER –&CHROMOSOMAL
acidemia ANOMALY
 CARDIOMYOPATHY, VIRAL MYOCARDITIS
 TACHYARRYTHMIA
 CONG. CARDIAC ANAMOLY- ebstein s anomaly
 TTS
 CARDIAC FAILURE DUE TO AV MALFORMATION
[VEIN OF GALEN ANEURYSM, LARGE
HAEMANGIOMA,CHORIOANGIOMA OF PLACENTA

 ANATOMICALY ABSENT DV
DV: [1st trimester ]
 Abnormal blood flow demonstrated as
reversed a wave in the ductus
venosus is seen in 80 % of fetuses
with trisomy 18 and 5 % of euploid
fetuses.
 CAUTION
:
 DV sampling in 1ST trimester is
only if NT is abnormal
 indicated
 DV sampling in IUGR fetus is indicated if
 umbilical, MCA or both are abnormal
 Loss of ‘M’ pattern is observed when there is excessive fetal
movement, breathing movement, post prandial state, with
hyperdynemic circulation
 IVC Doppler
 They found that recording the Doppler
spectrum between the renal vessels and
the subdiaphragmatic hepatic veins or
below the ductus venosus provided the
best reproducibility,the most favorable
beam-vessel angle, and the least variation.
 At this site the inferior vena cava is
scanned in a longitudinal parasagittal
plane at a low insonation angle ( < 30°).
 Interpreting the frequency
spectrum.
 As in the ductus venosus, the waveform of the
inferior vena cava reflects the systolic and diastolic
phases of the cardiac cycle and therefore reflects the
intracardiac pressures.

 Unlike the ductus venosus. the inferior vena cava

waveform exhibits a bidirectional, triphasic flow pattern
with a retrograde component during atrial contraction.

 Additionally, the flow velocities in the inferior vena cava

are one-half to one-third the velocities in the ductus
venosus
Normal Doppler frequency spectrum
recorded from the inferior vena cava
 In healthy fetuses, significant decrease of the reversed
flow during atrial contraction is seen with the advancing
gestation.
 These are due to improved ventricular compliance and
due to reduction in the right ventricular afterload caused
by the fall in placental resistance as the pregnancy
advances.
 In IUGR fetuses the IVC is characterized by increase in
reversed flow during atrial contraction.
 This increase is due to abnormal ventricular filling
characteristics, an abnormal ventricle chamber,or wall
compliance.
 Umbilical vein doppler
 The umbilical vein waveform generally shows a
monophasic pattern with a mean flow velocity of 10-
15 cm/s.
 The presence of umbilical vein pulsations in the
second or third trimester may signify a cardiac
anomaly, arrhythmia, or congestive heart disease.
 Pulsations in the umbilical vein may occur as single
or double pulsations or may produce a triphasic
Doppler spectrum.
 A markedly increased mortality rate of 50-60% is
reported in cases where these flow patterns are
detected.
Doppler frequency spectra of the umbilical vein in
various fetal states.
 Summary of venous doppler
 Venous Doppler also reflects cardiovascular response to
increased placental resistance
 Increased cardiac work required to perfuse abnormally
resistive placenta
 Right ventricle is the fetal systemic ventricle
 RV decompensation ~ tricuspid regurgitation
 Tricuspid regurgitation ~ increased right atrial pressure
 Increased right atrial pressure transmitted to venous
structures
 Inferior vena cava (lVC)
• Normal cyclical waveform reflects cardiac cycle
• Increased right atrial pressure ~ increased retrograde
flow in IVC
 DV
• With further decompensation retrograde flow occurs during
atrial contraction
 UV
• Normal flow is continuous, forward, non-pulsatile
• Regular pulse at end-diastole reflects elevated right heart
pressure
• Increased Right heart pressure transmitted to
IVC -> DV ->UV
• Pulsations not timed to end-diastole likely relate to fetal
breathing activity
• Tracing will normalize when breathing stops
• Pulsatile UV flow signifies advanced cardiac
decompensation
Very abnormal Doppler spectra recorded from the inferior vena cava, ductus venosus, and umbilical
vein of a fetus with severe intrauterine growth retardation (28 weeks, 5 days). The spectra are
temporally aligned for comparison.
The hypoxemic myocardial~nsufficiency causes an increase in right atrial pressure during atrial
contraction (- a). This is reflected in an increased retrograde component in the inferior vena
cava. a reverse flow component in the ductus venosus. and a twin-peak pulsation pattern with a
deep second notch in the umbilical vein.
 Role of venous doppler
 Venous Doppler scanning is mainly indicated in cases
that have shown absent or reverse end-diastolic flow in
the umbilical artery .

 The goal of venous Doppler in these cases is to provide

additional , noninvasive information on the functional
capacity of the fetal heart to help determine the optimum
timing of the delivery.

 This is particularly important before 30 weeks' gestation

in severely growth retarded fetuses in a setting of
chronic placental insufficiency. The essential goal in
these cases is to prolong the pregnancy by at least 1-2
days to allow for therapy to accelerate fetal lung
maturation.
FHR recording compared with arterial and venous Doppler spectra from a growth-
retarded fetus at 28 weeks. 2 days. The spectra indicate reverse flow in the umbilical
artery and descending aorta with a brain-sparing effect in the middle cerebral artery.
The venous system also shows a very abnormal Doppler frequency pattern.The ductus
venosus shows high pulsatility with a retrograde component during atrial contraction. The
other spectra show double pulsations in the umbilical vein and an increased retrograde
component in the inferior vena cava during atrial contraction. The FHR recording is
abnormal, showing decreased variability and slight deceleration
 FETAL CARDIAC DOPPLER
 Several planes Including the abdominal view, four-chamber,
five-chamber, short-axis and three-vessel views have to be
assessed.
 When adding color Doppler to your grayscale image, select
high-velocity scales given that the velocity of cardiac blood
flow is higher than the peripheral fetal circulation.
 By adjusting your filters to a high setting and by directing the
angle of insonation of your ultrasound beam parallel to the
direction of blood flow, the color Doppler image is optimized
and wall motion artifact is significantly reduced.
 The insonating angle should be within 15 to 20 degrees of
the direction of blood flow, Doppler waveforms should be
obtained during fetal apnea, and multiple measurements
should be made.
 The fetal circulation is in parallel rather than in series, and the
right ventricular cardiac output is greater than the left
ventricular cardiac output
 Doppler waveforms across the atrioventricular valves are
bicuspid in shape .
 The first peak (E wave),corresponds to early ventricular filling
of diastole, and the second peak (A wave) corresponds to
atrial systole or the atrial kick.

 Unlike in postnatal life, the velocity of the A wave is higher

than that of the E wave in the fetus.This highlights the
importance of the role that atrial systole plays in cardiac filling
in fetus.
 The E/A ratio increases and approaches near 1 with advancing
gestation and reflects ventricular diastolic function,suggesting
that atrial systole becomes less important with maturation of
ventricle myocardium.

 E and A velocity peaks are higher in the right ventricle, and this
right ventricular dominance is noted from the first trimester.

 Shifting to left ventricular dominance starts in utero toward the

end of gestation.The E/A ratio is an index of ventricular preload
and compliance
Flow velocity waveform at tricuspid
valve at 28 wks gestation
 Normograph

 This E/A ratio increases during pregnancy

to 1 ,reversed after birth.
 The ratio between the E and A waves (E/A) is a
widely accepted index of ventricular diastolic function
and is an expression of both the cardiac compliance
and preload conditions
 In IUGR fetuses,the E/A ratio is higher than that of
normal fetuses,due to changes in preload without
impairment of fetal myocardium diastolic function
( Increased preload causes decreased ‘A’
wave,thereby increasing E/A ratio).
 In most severe cases there is mitral and tricuspid
regurgitation.
 Tricuspid regurgitation evidenced by color Doppler ultrasonography
(arrow). The pulsed Doppler image shows the TV waveforms above the
baseline, with the E and A waveforms, and olosystolic regurgitation
(arrows) below the baseline
 Doppler waveforms across the semilunar valves are
uniphasic in shape
 Indices most commonly used for the semilunar Doppler
waveforms include the peak systolic velocity (PSV)
and the time to peak velocity (TPV).
 PSV and TPV increase with advancing gestation across
the semilunar valves.
 PSV is higher across the aorta than across the
pulmonary artery owing to a decreased afterload and a
smaller diameter across the aorta.
 These Doppler indices reflect ventricular
contractility,arterial pressures, and afterloads
Doppler waveform
across aortic valve
flow velocity
waveforms from the
aorta and pulmonary
arteries are recorded
respectively from the
five-chamber and
short-axis views of the
fetal heart
 Doppler indices that are commonly used in fetal
echocardiography

A, Peak-systolic velocity PV
B, time velocity integral TVI
C, time-to peak velocity
TPV
 Measurement of cardiac output and
ventricular ejection fraction(VEF)
 Formula for cardiac output is
Q = TVI x HR x A
Q=absolute flow per minute, A=area of the valve,HR=heart rate
TVI=time velocity integral is a measure of length of the column of blood.
 VEF is calculated according to Newton's second law of motion i.e the
force as the product of mass and acceleration
VEF = (1.055.'valve area' .FVI AT)
 FVI AT is PV/TPV
 The mass in this model is the mass of blood accelerated into the outflow
tract over a time interval, and may be calculated as the product of the
density of blood (1.055),the valve area and the flow velocity time integral
during acceleration (FVI AT), which is the area under the Doppler spectrum
envelope up to the time of peak velocity.
 IUGR is associated with several
changes at the level of the fetal heart
involving preload, afterload, ventricular
compliance, and myocardial
contractility.
 These arterial Doppler abnormalities are followed by
abnormalities in

right cardiac diastolic indices

right cardiac systolic indices

left cardiac diastolic indices

left cardiac systolic indices

Preserving the left systolic function as the last variable to become

abnormal ensures an adequate left ventricular output, which
supplies the cerebral and coronary circulations
 Doppler staging of Intrauterine
Growth-Restricted Fetuses
Stage Doppler finding
Stage I An abnormal UA
An abnormal MCA PI
Stage II An abnormal MCA PSV
Absent/reversed diastolic velocity in the UA
UV pulsation
An abnormal DV PI(an absent DV A wave is
considered part of this stage)
Stage III DV reversed flow
UV reversed
flow
An abnormal TV
E/A ratio i.e. >1
Each stage was further Tricuspid
divided into A and B when the AFI was less than or
regurgitation
greater than 5 cm, respectively
 Stage I

A, Abnormal UA Doppler flow. The arrows point to the low diastole, indicating high
placental resistance.
B, Abnormal MCA Doppler flow at 27 weeks’ gestation. The vertical arrows point
to the diastole, which is increased, indicating a “brain-sparing effect”; the
horizontal arrows indicate the PSV, which appears normal. An abnormal PI in
either the UA or MCA characterizes stage I.
Stage II-Abnormal MCA waveform,absent and reversed
umbilical artery,low a wave with high PI in DV
 Stage
III

Reversed flow in DV Reversed flow in UV

an abnormal TV waveform (E/A ratio >1).

 Stage I fetuses have mild IUGR, and we can treat these
patients as outpatients, whereas stage II and III
patients need to be admitted to the hospital.

 Stage II patients are admitted for observation, whereas

stage III patients are at high risk for fetal death.

 At the other extreme, the mortality for stage III fetuses

was high
50 % if DV flow is reversed,
85 % if DV flow is reversed with one of
parameters of stage III) whereas the mortality in stage II
fetuses was intermediate between the 2 other stages
 Doppler in TTTS

 Occur in monochorionic twins

 Doppler measurement of umbilical artery has
excellent prognostic role to assess patients with
TTTS.
 Serial evaluation is important in timing and choice of
fetal intervention.
 Abnormal doppler findings are absent or reversed
end diastolic flow in umb artery,reversed flow in DV
or pulsatile flow in umbilical vein in recipient fetus.
 Treatmentinclude conservative
management,serial amnioreduction,laser
photocoaglation of communication
vessels,septostomy,selective foeticide.

 When twin undergo laser therapy or

amnioreduction, the MCA PSV allows
diagnosis of fetal anemia and indicates need
for IUT in recipient after laser therapy.
 Obstetric doppler applications
An overview

 Upto 11 wks – Far, few or none

 11 to14 wks – Aneuploidy screening

 2nd Trimester – Congenital anomalies [e.g. aneurysm of

vein of Galen, teratoma in fetal neck, d/d lung
sequestration from micro cystic CCAM , vascular hepatic
tumors, cardiac], Uterine a. Doppler

 3rd Trimester – Fetal Well being

CONTINUOUS WAVE AND PULSED WAVE
 As the name suggests, continuous wave systems use continuous
transmission and reception of ultrasound.
 Doppler signals are obtained from all vessels in the path of the
ultrasound beam (until the ultrasound beam becomes sufficiently
attenuated due to depth).
 Continuous wave Doppler ultrasound is unable to determine the
specific location of velocities within the beam and cannot be used to
produce color flow images.
 Relatively inexpensive Doppler ultrasound systems are available
which employ continuous wave probes to give Doppler output
without the addition of B-mode images.
 Continuous wave Doppler is also used in adult cardiac scanners to
investigate the high velocities in the aorta.
• Doppler ultrasound in general and obstetric ultrasound scanners uses pulsed
wave ultrasound.
• This allows measurement of the depth (or range) of the flow site.
• Additionally, the size of the sample volume (or range gate) can be changed.
Pulsed wave ultrasound is used to provide data for Doppler sonograms and
color flow images.
 Doppler studies in red blood cell isoimmunization
 Doppler studies in pregnancies with maternal diabetes mellitus
 Doppler studies of the fetal heart
 Doppler studies in preterm prelabor amniorrhexis
 Doppler studies in maternal autoimmune disease ;Systemic lupus
erythematosus, Antiphospholipid syndrome
 Doppler studies in post-term pregnancies
 Doppler studies in twin pregnancy
 Chorionicity in twins
 Pregnancy complications
 Doppler studies in twins
 Doppler studies in twin-to-twin transfusion syndrome
 Color Doppler sonography in the assessment of the fetal heart : Examination
of the normal heart vs of the abnormal heart
 Differential diagnosis of tricuspid regurgitation
 Color Doppler sonography in the diagnosis of fetal abnormalities