The role of uterine artery Doppler in predicting adverse pregnancy outcome

doi:10.1016/j.bpobgyn.2004.02.003

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 18, Issue 3, June 2004, Pages 383-396

https://doi.org/10.1016/j.bpobgyn.2004.02.003 Get rights and content

Abstract

The complications of placental insufficiency, pre-eclampsia and fetal growth restriction (FGR) are major causes of perinatal as well as maternal morbidity and mortality. In normal pregnancy, impedance to flow in the uterine arteries decreases with gestation, and histopathological studies suggest that this is due to trophoblastic invasion of the spiral arteries and their conversion into low-resistance vessels. Failure of trophoblastic invasion is associated with complications of uteroplacental insufficiency. Several Doppler screening studies, both in the second and more recently in the first trimester of pregnancy, have demonstrated an association between increased impedance to flow in the uterine arteries and subsequent development of pre-eclampsia, FGR and perinatal death.

Section snippets

Impaired placentation: pathophysiology

In uncomplicated pregnancies, the spiral arteries undergo a series of changes that convert them from small-diameter, high-resistance vessels into low-resistance non-responsive channels.¹ In some cases there is defective trophoblastic invasion² and an inadequate maternal vascular response to placentation, and this is associated with subsequent development of pre-eclampsia and fetal growth restriction (FGR).3., 4. In these pregnancies, the uteroplacental circulation remains in a state of high

Doppler ultrasound of the uteroplacental circulation

Blood flow through the uteroplacental circulation can be studied non-invasively using Doppler ultrasound.¹⁰ The impedance to flow in the uterine arteries decreases with gestation in normal pregnancies, reflecting the trophoblastic invasion of the spiral arteries and their conversion into low-resistance vessels. Studies in pregnancies with established pre-eclampsia or fetal growth restriction have shown that impedance to flow in the uterine arteries is increased10., 11., 12., 13., and this is

Summary

There is evidence that increased impedance to flow in the uterine arteries is associated with increased risk for subsequent development of pre-eclampsia, FGR and perinatal death. In addition, women with normal impedance to flow in the uterine arteries constitute a group that have a low risk of developing obstetric complications related to uteroplacental insufficiency.

One-stage screening tests in pregnancies attending for routine antenatal care at 23–24 weeks suggest that increased impedance

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Cited by (195)

Is a sFlt-1/PlGF cutoff of 38 suitable to predict adverse outcomes in pregnancies with abnormal uterine artery Doppler velocimetry in the second trimester?
2023, Pregnancy Hypertension
To determine the optimal cutoff value for the soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio to predict maternal and fetal adverse events in pregnancies with uterine artery Doppler scans results above the 95th percentile in the late second trimester.
Retrospective, observational cohort study on 116 asyntomatic patients with abnormal uterine artery Doppler scans at gestational week 25. The sFlt-1/PlGF ratio was determined within the weeks 25 to 29 of gestation and ROC curve analysis performed. The diagnostic validity of different cutoff values to predict severe maternal and fetal complications, i.e. preeclampsia, fetal growth restriction, placental abruption, and fetal death, was analyzed.
An ideal cutoff for sFlt-1/PlGF ratios in pregnancies with abnormal uterine artery Doppler in the second trimester.
Applying a cutoff point of 38, the area under the ROC curve was 0.89, generally considered low risk in fetal and maternal complication prediction. The sensitivity was 32.1%, the specificity 98.4%, the positive predictive value (PPV) 94.4%, and the negative predictive value (NPV) 63.3%. A cutoff value of 10, leading to the highest Youden index, performed best at detecting overall complications, increasing sensitivity to 69.8% and the NPV to 76.8%. at the cost of a reduced specificity and PPV.
In pregnancies with abnormal uterine artery Doppler in the second trimester, an sFlt-1/PlGF cutoff value greater than equal to 38 improves its predictive power for adverse events.
Maternal Hypertensive Disorders of Pregnancy and Cardiac Structure and Function in the Newborn
2022, JACC: Advances
Maternal hypertensive disorders of pregnancy (HDPs) are strongly associated with offspring congenital heart defects.
This study assessed whether infants exposed to maternal HDPs were also more likely to have subtle cardiac structural and functional abnormalities than unexposed infants.
We used regression analyses to compare: 1) left ventricular parameters from conventional echocardiography performed in infants from the Copenhagen Baby Heart Study born to mothers with preeclampsia, gestational hypertension (GH), or no HDP; and 2) advanced echocardiographic parameters for 545 term infants born to mothers with preeclampsia and 545 matched infants not exposed to HDPs.
Compared with infants unexposed to HDPs (n = 17,384), infants exposed to preeclampsia (n = 754) had a thicker interventricular septum in end-diastole (adjusted mean difference [± SD] 0.05 [±0.02] mm; P = 0.004), thicker left ventricular posterior wall (0.04 [±0.02] mm; P = 0.009), larger left ventricular internal diameter (0.12 [±0.06] mm; P = 0.04), and larger left ventricular volume (0.21 [±0.10] mL; P = 0.03). Systolic function changes included increased fractional shortening (0.36% [±0.14%]; P = 0.01) and stroke volume (0.18 [±0.07] mL; P = 0.006), whereas diastolic function changes included lower transmitral early peak inflow velocity (−1.76 [±0.49] mL; P = 0.0003), lower mitral annulus lateral wall a' (−0.21 [±0.09] cm/s; P = 0.02), and smaller lateral E/e’ (−1.06 [±0.38] cm/s; P = 0.005). Conversely, there was little evidence of any association between maternal GH (n = 469) and offspring left ventricular parameters.
Maternal preeclampsia, but not GH, was associated with subtle newborn cardiac morphological and functional alterations, including thickening of the left ventricular myocardium and altered systolic and diastolic function.
Pravastatin plus L-arginine prevents adverse pregnancy outcomes in women with uteroplacental vascular dysfunction
2021, Vascular Pharmacology
Uteroplacental vascular dysfunction, characterized by diminished uterine artery (UtA) blood flow in the second trimester is a clinically useful predictor of the further development of preeclampsia, fetal growth restriction and stillbirth. Efforts to develop effective treatments to protect pregnancies with abnormal UtA Dopplers would be of significant clinical benefit for mothers and their fetuses.
The aim of this pilot non randomized control study was to use pravastatin +L-arginine to improve uteroplacental haemodynamics and prevent adverse maternal and neonatal outcomes in women with abnormal Dopplers and high risk for developing adverse pregnancy outcomes.
This study was performed between 2015 and 2018. All women received primary care at OB/GYN Polyclinic Jurisic and Narodni Front University Hospital, University of Belgrade Medical School, Serbia. Approval for investigational drug use was obtained and all women gave informed consent.
10 pregnant women with a poor obstetric history that developed uteroplacental dysfunction (UtA pulsatility index (PI) above the 95th percentile and notching) at 20.5 weeks IQR [17.7–22] gave consent to be treated daily with pravastatin (40 mg) and L-arginine (1.5 g) to improve placental blood flow and pregnancy outcomes. 5 women remained untreated after diagnosis at 21 weeks [20−22] (control group). Due to presence of risk factors for pregnancy complications, close maternal and fetal monitoring was undertaken in all patients. Doppler examinations were performed to monitor changes in placental vascular resistance and fetal well-being and growth.
PRAV+L-arginine improved uteroplacental haemodynamics, increased fetal growth and prevented early onset preeclampsia leading to delivery close to term (delivery date: median 38 weeks, IQR[36.5–39]) and appropriate weight for gestational age compared to controls, in which placental blood flow did not improve and 2 women developed severe early onset preeclampsia. Neonates from the control group were born preterm (25 weeks IQR[23.5–25]), growth restricted and spent several months at NICU. Two neonates died due to prematurity-associated complications. PRAV+L-arginine treatment prolonged pregnancies for 4.1 months, compared to 26 days in the untreated group, preventing neonatal complications associated with prematurity. The infants are now 1–3 years old and show normal growth and development.
This study describes the successful management with pravastatin+L-arginine of 10 pregnant patients with uteroplacental vascular dysfunction and high risk of adverse maternal and fetal outcomes. A larger study is being organized to confirm these observations.
Longitudinal changes in maternal left atrial volume index and uterine artery pulsatility indices in uncomplicated pregnancy
2021, American Journal of Obstetrics and Gynecology
Data on the relationship between longitudinal changes in maternal volume-dependent echocardiographic parameters and placentation in uncomplicated pregnancy are limited.
This study aimed to evaluate changes in volume-dependent echocardiographic parameters in uncomplicated pregnancy to test the hypothesis of the existence of an association between volume-dependent echocardiographic parameters and Doppler ultrasound parameters of fetal circulation and the uterine artery in uncomplicated pregnancy and to establish which of the volume-dependent echocardiographic parameters best depicts volume changes and correlates best with Doppler ultrasound of fetal circulation and the uterine artery in healthy pregnancy.
Data from 60 healthy pregnant women were analyzed. A complete echocardiographic study was performed at 11 to 13, 20 to 22, and 30 to 32 weeks’ gestation: left ventricular end-diastolic volume, early diastolic peak flow velocity, late diastolic peak flow velocity, left atrial area, and left atrial volume index were assessed. Obstetrical assessment was performed including fetal growth and uterine artery pulsatility index. Fetal well-being was assessed by umbilical and middle cerebral artery blood flow. Serum pregnancy-associated plasma protein A and free β-human chorionic gonadotropin were assessed during the routine first-trimester scan (11–13 weeks’ gestation).
Left ventricular end-diastolic volume and left atrial area increased significantly between 11 to 13 and 20 to 22 weeks’ gestation but not between 20 to 22 and 30 to 32 weeks’ gestation. Left atrial volume index measured at 30 to 32 weeks’ gestation correlated with uterine artery pulsatility indices in 3 trimesters. Changes in the left atrial volume index between the third and first trimesters correlated significantly with the uterine artery pulsatility index measured at 20 to 22 weeks’ gestation (r=−0.345; P=.020) and at 30 to 32 weeks’ gestation (r=−0.452; P=.002). Changes in the left atrial volume index between the second and first trimesters significantly correlated with the uterine artery pulsatility index measured in the first trimester (r=−0.316; P=.025).
Our study showed that in an uncomplicated pregnancy, among volume-dependent echocardiographic parameters, left atrial volume index increased between both the first and second trimesters and the second and third trimesters and correlated with parameters of Doppler ultrasound of the fetal circulation and the uterine artery. Our results expand on the previous observation on the relationship between maternal cardiovascular adaptation and placentation in women with heart diseases to the population of healthy women with uncomplicated pregnancy.
Fetal Growth and Growth Restriction
2019, Fetal Medicine: Basic Science and Clinical Practice
Can placental shear wave elastography predict preeclampsia in high-risk pregnant women during second trimester? Insights from a prospective cohort study
2024, Egyptian Journal of Radiology and Nuclear Medicine

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2The role of uterine artery Doppler in predicting adverse pregnancy outcome

Abstract

Section snippets

Impaired placentation: pathophysiology

Doppler ultrasound of the uteroplacental circulation

Summary

Placenta

Placenta

American Journal of Obstetrics and Gynecology

European Journal of Obstetrics Gynecology and Reproductive Biology

Lancet

Clinical Obstetrics and Gynaecology

American Journal of Obstetrics and Gynecology

American Journal of Obstetrics and Gynecology

Lancet

Early Human Development

Obstetrics and Gynecology

The physiological response of the vessels of the placental bed to normal pregnancy

Journal of Pathology and Bacteriology

Inadequate maternal vascular response to placentation in pregnancies complicated by pre-eclampsia and by small-for-gestational age infants

British Journal of Obstetrics and Gynaecology

Placental bed spiral arteries in the hypertensive disorders of pregnancy

British Journal of Obstetrics and Gynaecology

Fetal growth retardation and the arteries of the placental bed

British Journal of Obstetrics and Gynaecology

2
The role of uterine artery Doppler in predicting adverse pregnancy outcome