Doppler blood flow in obstetrics

Doppler ultrasound can be used to monitor umbilical arterial blood flow in lightly sedated pigs at multiple gestational ages

Doppler ultrasound was performed under moderate sedation (ketamine and azaperone) for 30min to monitor umbilical arterial (UA) blood flow in one uterine horn of Large White×Landrace gilts (n=23) at Gestational Days (GD) 30, 45, 60 and 90. Gilts were scanned before they were killed to examine relationships between litter size, sex ratio and five UA parameters (peak systolic velocity (PSV), end diastolic velocity (EDV), A/B (PSV to EDV) ratio, fetal heart rate (FHR) and resistance index (RI)). In gilts in which scans were obtained from all fetuses in the scanned horn, relationships between UA parameters, and fetal weight and sex were examined. A subset of gilts were sedated, scanned and recovered (SSR) earlier in gestation (GD30 or GD45) to assess the effects of sedation on later fetal development by comparison with control litters (no previous sedation). Temporal changes were observed in all UA parameters (P≤0.001). At GD60 and GD90, FHR decreased with increasing duration of sedation (P≤0.001). Sex ratio and fetal weight affected UA blood flow, whereas litter size and fetal sex did not. SSR at GD30 and GD45 was associated with decreased fetal weight at GD60 (P≤0.001) and GD90 (P=0.06) respectively, compared with controls. These results suggest maternal sedation during gestation affects fetal development, which should be investigated further. Measuring UA blood flow in growth-restricted porcine fetuses throughout gestation may be feasible.

Arginine vasopressin infusion is sufficient to model clinical features of preeclampsia in mice

Copeptin, a marker of arginine vasopressin (AVP) secretion, is elevated throughout human pregnancies complicated by preeclampsia (PE), and AVP infusion throughout gestation is sufficient to induce the major phenotypes of PE in mice. Thus, we hypothesized a role for AVP in the pathogenesis of PE. AVP infusion into pregnant C57BL/6J mice resulted in hypertension, renal glomerular endotheliosis, intrauterine growth restriction, decreased placental growth factor (PGF), altered placental morphology, placental oxidative stress, and placental gene expression consistent with human PE. Interestingly, these changes occurred despite a lack of placental hypoxia or elevations in placental fms-like tyrosine kinase-1 (FLT1). Coinfusion of AVP receptor antagonists and time-restricted infusion of AVP uncovered a mid-gestational role for the AVPR1A receptor in the observed renal pathologies, versus mid- and late-gestational roles for the AVPR2 receptor in the blood pressure and fetal phenotypes. These findings demonstrate that AVP is sufficient to initiate phenotypes of PE in the absence of placental hypoxia, and indicate that AVP may mechanistically (independently, and possibly synergistically with hypoxia) contribute to the development of clinical signs of PE in specific subtypes of human PE. Additionally, they identify divergent and gestational time-specific signaling mechanisms that mediate the development of PE phenotypes in response to AVP.

Reference range of gestational uterine artery resistance index in small canine breeds

The objectives of this study were to evaluate the uterine artery blood flow during the second half of normal pregnancy in small breed dogs and to determine the RI reference values of this artery in these bitches. Fifty-two, 1.5-6.5 kg, purebred healthy pregnant bitches were included in this study. Doppler ultrasonographic examinations of the uterus were performed every 10 days from Day 30 of the estrous cycle to parturition. Peak systolic velocity (PSV) and end diastolic velocity (EDV) of the uterine artery were measured while RI [(PSV-EDV)/PSV] was automatically calculated. Values of PSV, EDV and RI were analyzed by repeated measures ANOVA followed by Tukey test using age, body weight, litter size and parity as covariates. Resistance index reference ranges were constructed by regressing this index on gestational age. Equation of the polynomial regression curves was used to calculate the mean, 95th and 5th centiles for each gestational age (GA). A gradual increase of PSV (P < 0.01) and EDV (P < 0.01) and a decrease in RI (P < 0.01) were found throughout the study period. PSV and EDV were influenced by litter size (P < 0.05), while RI was not. None of the Doppler parameters were influenced by age, body weight or parity. A second-degree polynomial described the relationship between RI of uterine artery and GA in the different time points: [RI = 0.993 + 8.4x10-5 x GA2- 0.0117 x GA]. It is concluded that uterine artery blood flow progressively increased throughout normal pregnancy in small breed bitches. In addition, reference ranges of uterine artery RI were 0.64-0.79, 0.57 to 0.75, 0.53 to 0.71 and 0.52 to 0.66 on Days 30, 40, 50 and 60 of gestation, respectively.

Doppler ultrasonographic assessment of maternal and fetal arteries during normal feline gestation

The aim of this study was to describe Doppler parameters of uterine, umbilical, fetal abdominal aorta, fetal renal and fetal internal carotid arteries, as well as fetal heart rate (FHR), during normal feline gestation. Fifteen, 1-4 years of age, weighing 2.5-3.9kg, domestic short-hair pregnant queens, which were born in our institutional cat colony were included in this study. Color and pulsed-wave Doppler evaluations of uterine arteries were performed every 10 days (Day 0, 10, 20, 30, 40, 50, 60) from mating. Fetal Doppler and M-mode ultrasonography were performed to assess umbilical, fetal abdominal aorta, fetal renal, fetal internal carotid arteries and FHR. Both peak systolic velocity (PSV) and end diastolic velocity (EDV) of uterine artery increased up to parturition (P<0.01), while resistance index (RI) decreased from Day 10 onwards (P<0.01). From Day 40 onwards, RI of umbilical artery diminished, while PSV and EDV augmented (P<0.01). Fetal abdominal aorta (P<0.01), renal (P<0.01) and internal carotid (P<0.01) arteries diminished their RI from Days 40, 60 and 40 onwards, respectively. Both PSV and EDV of these three arteries increased progressively. Fetal heart rate was first registered on Day 20 when it began to increase up to Day 40 and then diminished to the end of gestation (P<0.01). It is concluded that blood flow of uterine, umbilical, fetal abdominal aorta, fetal renal and fetal internal carotid arteries progressively increased during normal feline pregnancy, while FHR rose to mid gestation and then decreased up to parturition.

Doppler ultrasound evaluation in preeclampsia

Background

Worldwide preeclampsia (PE) is the leading cause of maternal death and affects 5 to 8% of pregnant women. PE is characterized by elevated blood pressure and proteinuria. Doppler Ultrasound (US) evaluation has been considered a useful method for prediction of PE; however, there is no complete data about the most frequently altered US parameters in the pathology. The aim of this study was to evaluate the uterine, umbilical, and the middle cerebral arteries using Doppler US parameters [resistance index (RI), pulsatility index (PI), notch (N), systolic peak (SP) and their combinations] in pregnant women, in order to make a global evaluation of hemodynamic repercussion caused by the established PE.

Results

A total of 102 pregnant Mexican women (65 PE women and 37 normotensive women) were recruited in a cases and controls study. Blood velocity waveforms from uterine, umbilical, and middle cerebral arteries, in pregnancies from 24 to 37 weeks of gestation were recorded by trans-abdominal examination with a Toshiba Ultrasound Power Vision 6000 SSA-370A, with a 3.5 MHz convex transducer. Abnormal general Doppler US profile showed a positive association with PE [odds ratio (OR) = 2.93, 95% confidence interval (CI) = 1.2 - 7.3, P = 0.021)], and a specificity and predictive positive value of 89.2% and 88.6%, respectively. Other parameters like N presence, RI and PI of umbilical artery, as well as the PI of middle cerebral artery, showed differences between groups (P values < 0.05).

Conclusion

General Doppler US result, as well as N from uterine vessel, RI from umbilical artery, and PI from umbilical and middle cerebral arteries in their individual form, may be considered as tools to determine hemodynamic repercussion caused by PE.

Suppression of trophoblast uterine spiral artery remodeling by estrogen during baboon pregnancy: impact on uterine and fetal blood flow dynamics

The present study was conducted to determine the impact of suppressing trophoblast remodeling of the uterine spiral arteries by prematurely elevating estrogen levels in the first trimester of baboon pregnancy on uterine and umbilical blood flow dynamics. Uteroplacental blood flow was assessed by Doppler ultrasonography after acute administration of saline (basal state) and serotonin on days 60, 100, and 160 of gestation (term: 184 days) to baboons in which uterine spiral artery remodeling had been suppressed by the administration of estradiol on days 25-59 of gestation. Maternal blood pressure in the basal state was increased (P < 0.01), and uterine artery diastolic notching and the umbilical artery pulsatility index and systolic-to-diastolic ratio, reflecting downstream flow impedance, were increased (P < 0.01) after serotonin administration on day 160, but not earlier, in baboons treated with estradiol in early gestation. These changes in uteroplacental flow dynamics in serotonin-infused, estradiol-treated animals were accompanied by a decrease (P < 0.05) in uterine and umbilical artery volume flow and fetal bradycardia. The results of this study show that suppression of uterine artery remodeling by advancing the rise in estrogen from the second trimester to the first trimester disrupted uteroplacental blood flow dynamics and fetal homeostasis after vasochallenge late in primate pregnancy.

Laparoscopy guided Doppler ultrasound measurement of fetal blood flow indices during early to mid-gestation in pigs

The objectives of this study were to obtain relevant blood flow indices of umbilical arteries (UmA) of porcine fetuses using a laparoscopic ultrasound probe and to relate these data with fetal size at early to mid gestation. Fetal parameters and flow indices, i.e., fetal length and area, fetal heart rate (FHR), systolic pulse duration (T1), interpulse duration (T2), T2/T1 ratio, peak systolic velocity (PSV), time averaged velocity (TAV), resistance index (RI) and pulsatility index (PI), were measured in 182 fetuses of 26 pregnant Landrace gilts on pregnancy day (PD) 36 (122 fetuses from 17 gilts), PD42 (19 fetuses from 3 gilts) and PD51 (42 fetuses from 6 gilts). Fetal heart rate was higher on PD36 than on PD42 (P<0.05). No differences (P>0.05) were obtained concerning systolic pulse duration, flow velocities and RI. On PD42, the PI was lower (P<0.05), while the interpulse duration (P=0.06) and T2/T1 ratio tended (P=0.08) to be higher on PD42 compared with PD36 and to PD51. To find differences in UmA blood flow parameters concerning fetal size, i.e., fetal length, fetuses were retrospectively grouped as follows: small (lower 25%), medium (mean 50%) and large (upper 25%), respectively. Although, fetuses differed in size (P<0.001) within and between days of pregnancy, FHR, PSV, TAV, RI and PI did not differ (P>0.05) among the size classes. Only systolic pulse duration tended to be longer (P=0.05) in large compared with small fetuses on PD36, and interpulse duration was lower in large fetuses on PD36 in comparison with PD51 (P<0.05). Though there was no link between fetal blood flow indices and fetal intrauterine growth retardation (IUGR), with further studies based on these flow indices, it might be possible to evaluate nutrient- or stress-related influences on fetal growth and development, particularly in the case of IUGR.

Doppler ultrasonographic assessment of maternal and fetal blood flow in abnormal canine pregnancy

The aim of this study was to describe the changes of uterine artery, umbilical artery and fetal abdominal aorta, renal and internal carotid arteries blood flow in abnormal canine pregnancy. Twenty-two, Brucella-negative pregnant bitches were retrospectively classified into abnormal (which had either interrupted their pregnancy between days 52 and 60 or had perinatal death >60% of the litter; n=11) and normal (which had delivered healthy puppies at term; n=11). In all the animals, color and pulsed-wave Doppler examinations of uterine artery were conducted every 10 days from Day 20 to 50 from estimated luteinizing hormone peak. Doppler ultrasonography was also conducted in the fetuses to assess umbilical artery, abdominal aorta, renal and internal carotid arteries from Day 40 to 60 of gestation. Throughout the study, resistance index (RI) of uterine, umbilical and fetal renal arteries decreased up to -15% compared to -36% (P<0.01), -11% compared to -23% (P<0.05) and 2% compared to -13% (P<0.05), respectively in the abnormal and normal bitches. Fetal abdominal aorta and internal carotid did not differ between groups (P>0.05). It is concluded that in dogs, uterine artery, umbilical artery and fetal renal artery RI differ between normal and abnormal gestation being useful for the prediction of adverse obstetric outcome.

Uterine and fetal blood flow indexes and fetal growth assessment after chronic estrogen suppression in the second half of baboon pregnancy

Although estrogen regulates important aspects of maternal cardiovascular physiology, the role of estrogen on uteroplacental and fetal blood flow is incompletely understood. This study tested the hypothesis that chronically suppressing endogenous estrogen production during the second half of baboon pregnancy alters uterine and fetal blood flow dynamics assessed by ultrasonography. Pregnant baboons were untreated or treated daily with the aromatase inhibitor letrozole or letrozole plus estradiol on days 100-160 of gestation (term = 184 days). Blood flow dynamics were determined by Doppler ultrasonography on day 60 and longitudinally between days 110 and 160 of gestation. Letrozole decreased maternal serum estradiol and estrone concentrations by 95% (P < 0.001). Fetal growth biometrical parameters increased (P < 0.001) between days 110 and 160 of gestation and were similar in untreated and letrozole-treated animals. Uterine, umbilical, and fetal middle cerebral artery pulsatility index and resistance index declined (P < 0.01) by 30-50% and uterine artery volume flow increased sixfold (P < 0.001) between days 60 and 160, but values were similar in untreated, letrozole-treated, and letrozole plus estradiol-treated baboons. Thus uterine and fetal artery blood flow indexes, uterine artery volume flow, and fetal growth were maintained at normal levels despite chronic estrogen suppression in the second half of baboon pregnancy. This suggests that elevated levels of endogenous estrogen are not required to maintain low impedance blood flow within the uteroplacental vascular bed during the second half of nonhuman primate pregnancy.

Doppler ultrasound in canine pregnancy

OBJECTIVE

The aim of this article is to review the current knowledge of Doppler ultrasound in canine pregnancy. A brief introduction of Doppler principles and their applications in human obstetrics is also included.

METHODS

A review of the peer-reviewed published literature was conducted of the articles pertaining to the use of Doppler ultrasound in canine pregnancy, general Doppler principles, and Doppler applications in human obstetrics.

RESULTS

In bitches, Doppler ultrasound has been used to assess ovarian, uterine, umbilical, fetal aorta, common carotid artery, and fetal caudal vena cava blood flow during normal gestation. Most of these vessels increase their blood flow during normal pregnancy. The resistive index and systolic/diastolic ratio of the uterine arteries have been recently described in an experimental pharmacologically induced model of abnormal canine gestation. Both indices progressively increase up to abortion, probably because of progesterone deprivation. Moreover, resistive index abnormalities have been found in canine cases of spontaneous abnormal gestations as described in human medicine.

CONCLUSIONS

Doppler ultrasound is a useful method for assessing development of the placental and fetal circulation during normal and abnormal canine pregnancy. Further studies are still necessary to widely use this technique in clinical practice.

The value of umbilical artery Doppler velocimetry in the antenatal surveillance of uncomplicated monochorionic twin pregnancies

OBJECTIVES

To investigate the predictive value of abnormal umbilical artery Doppler findings on outcome in uncomplicated monochorionic (MC) twin pregnancies.

METHODS

Sixty-seven MC twin pregnancies, with antenatal care and delivery at the University Medical Center, Utrecht, The Netherlands, between 1999 and 2004, were studied. Pregnancies with antenatal signs of twin-to-twin transfusion syndrome were excluded. We analyzed the data according to both the last Doppler measurement of the umbilical artery before delivery and the presence of any abnormal Doppler measurement during the course of pregnancy. Risks of mortality and total neonatal morbidity were stratified according to the Doppler findings in one or both fetuses at the time of each standard ultrasound assessment in order to estimate the risk associated with an abnormal Doppler finding at or before that specific gestational age.

RESULTS

Mortality rates were similar in the normal and abnormal Doppler groups. Using both group definitions, total neonatal morbidity was higher in the abnormal Doppler group; this was significant at > 32 weeks' gestation, and was due to lower birth weight and earlier gestational age at delivery. There was no mortality at > or = 36 weeks in the abnormal Doppler group, but there were four perinatal deaths in the normal Doppler group. Gestational age at delivery was significantly lower when one or more abnormal Doppler findings had been present (median, 34 + 1 weeks vs. 36 + 3 weeks) and infants with abnormal Doppler findings weighed on average 261 g (95% CI, 21-502 g) less than those with normal findings.

CONCLUSIONS

In MC twins, abnormal Doppler flow of the umbilical artery identifies a subgroup at risk for preterm delivery, low birth weight and neonatal morbidity, but with a similar mortality risk to those with normal Doppler flow. At term, mortality occurred only in the group with normal Doppler findings, suggesting that fetal surveillance is insufficient in uncomplicated term MC twin pregnancies.

A Mathematical Basis for the Application of the Modified Geometric Method to Maximum Frequency Estimation

The application of ultrasound in assessing the fetal cardiovascular system often requires the accurate estimation of maximum blood flow velocity waveforms using Doppler measurements. The modified geometric method estimates the maximum Doppler frequency as the frequency at which the vertical distance between the integrated spectrum and the reference line that connects the origin to the maximum value of the integrated spectrum is the largest. This paper presents a mathematical formulation for a class of maximum blood flow velocity estimation algorithms that includes the modified geometric method. The analysis provides a rationale for the continued use of the modified geometric method for estimating the maximum frequency envelopes of Doppler signals. This paper also contains experimental results demonstrating the superiority of the modified geometric method over a commonly used threshold crossing method.