A possible new approach in the prediction of late gestational hypertension: The role of the fetal aortic intima-media thickness

The aim was to determine the predictive role of combined screening for late-onset gestational hypertension by fetal ultrasound measurements, third trimester uterine arteries (UtAs) Doppler imaging, and maternal history. This prospective study on singleton pregnancies was conducted at the tertiary center of Maternal and Fetal Medicine of the University of Padua during the period between January 2012 and December 2014. Ultrasound examination (fetal biometry, fetal wellbeing, maternal Doppler study, fetal abdominal aorta intima-media thickness [aIMT], and fetal kidney volumes), clinical data (mother age, prepregnancy body mass index [BMI], and parity), and pregnancy outcomes were collected. The P value <0.05 was defined significant considering a 2-sided alternative hypothesis. The distribution normality of variables were assessed using Kolmogorov–Smirnoff test. Data were presented by mean (±standard deviation), median and interquartile range, or percentage and absolute values. We considered data from 1381 ultrasound examinations at 29 to 32 weeks’ gestation, and in 73 cases late gestational hypertension developed after 34 weeks’ gestation. The final multivariate model found that fetal aIMT as well as fetal umbilical artery pulsatility index (PI), maternal age, maternal prepregnacy BMI, parity, and mean PI of maternal UtAs, assessed at ultrasound examination of 29 to 32 weeks’ gestation, were significant and independent predictors for the development of gestational hypertension after 34 weeks’ gestation. The area under the curve of the model was 81.07% (95% confidence interval, 75.83%–86.32%). A nomogram was developed starting from multivariate logistic regression coefficients. Late-gestational hypertension could be independently predicted by fetal aIMT assessment at 29 to 32 weeks’ gestation, ultrasound Doppler waveforms, and maternal clinical parameters

Assessment of Doppler velocimetry versus nonstress test in antepartum surveillance of high risk pregnancy

Background: High risk pregnancies increase the maternal and fetal morbidity and mortality; and there is a need for appropriate investigation which can diagnose it early and predicts the morbidity and mortality. The objectives of this study were to compare the efficacy of Doppler velocimetry studies and NST in predicting fetal compromise in utero and compare their ability in predicting the perinatal outcome in cases of high risk pregnancies.Methods: It was a prospective cross-sectional hospital based study conducted at Central Referral Hospital (CRH) which is a teaching hospital of Sikkim Manipal Institute of Medical Sciences (SMIMS). The study was conducted over a period of eighteen months between November 2012 and April 2014. One hundred consecutive cases of high risk pregnancies were enrolled into the study and investigated with NST (non-stress test) and Doppler velocimetry and results were correlated with perinatal outcome. In all cases, accurate gestational age was established from detailed menstrual history and ultrasonographic evidence of gestational age. Detailed examination, history and investigation were undertaken in each patient. Inclusion criteria were patients with singleton pregnancy beyond 34 weeks having one or more high risk factors. In these patients antenatal surveillance was done by Doppler and NST and results of these tests were correlated with perinatal outcome. Based on the Doppler velocimetry and NST results, the study population was divided in to four groups. Pregnant women below 34 weeks, multiple pregnancy and women with no risk factors were excluded from the study.Results: Maximum (63%) patients belonged to pregnancy induced hypertension (PIH) group, followed by oligohydramnios (11%), and gestational diabetes mellitus (GDM). The study showed that patients with both NST and Doppler waveform abnormal (group D) had the highest percentage of neonatal complication, NICU admissions and perinatal deaths. Even those patients with NST normal but Doppler velocimetry abnormal (group B) had comparatively higher neonatal complications. However, in group with NST abnormal and Doppler velocimetry normal (group C) had no fetal compromise. It was observed that normal NST and normal Doppler velocimetry were not statistically different in predicting fetal compromise and prediction value was low. But abnormal Doppler had statistically significant (p value = 0.021) predictive value in detecting fetal compromise. In cases with abnormal Doppler and fetal compromise, NST was still normal showing that abnormal Doppler waveform was better in predicting the bad perinatal outcome. Three out of 100 cases had absent end diastolic flow (AEDF) and all 3 were associated with perinatal morbidity with 2 perinatal deaths. Cerebroplacental ratio was < 1.08 in seven cases and all seven had neonatal complications including 3 neonatal deaths which also had AEDF. Thus, cerebroplacental ratio was better in detecting fetal compromise as compared to NST.Conclusions: Doppler velocimetry was better in predicting fetal compromise in comparison to NST in high risk pregnancies. Normal NST and normal Doppler velocimetry were not significantly different in prediction of fetal outcome. Abnormal Doppler value was better in predicting fetal compromise in comparison to abnormal NST

Prediction of preeclampsia by a combination of maternal spot urinary protein-creatinine ratio and uterine artery doppler

Background: Preeclampsia (PE) is heterogeneous disorder. The aim of the study was to observe the role of a spot urinary protein - creatinine ratio (UPCR) and uterine artery doppler velocimetry measured between 20-24 weeks of gestation in prediction of preeclampsia.Methods: Prospective observational study conducted on 120 pregnant mothers with singleton pregnancy between 20-24 weeks of gestational age in two tertiary teaching hospitals in eastern India. A spot urinary protein creatinine ratio (UPCR) was determined in a mid- stream urine sample and estimation of protein was done by immunoturbidimetric micro albumin method and creatinine by modified Jaffe’s method. Doppler velocimetry was also determined at 20-24 weeks of gestation. A notch in uterine artery, unilateral or bilateral; or RI > 0.7 and PI of > 1.45 were considered to have an abnormal result. Women were followed-up and relationship between variables was assessed by Chi- square test.Results: Women who subsequently developed preeclampsia had significantly higher UPCR (median 44.8 mg/mmol) when compared with women of unaffected groups (median 26.6 mg/mmol). The optimum spot urinary UPCR to predict preeclampsia was 35.5 mg/mmol and the cut-off value >35.5 mg/mmol had a test sensitivity (80%), specificity (94.06%), PPV (66.76%) and NPV (96.94%).The area under curve (AUC) of spot UPCR in ROC curve was  0.949 (95% CI,0.891 - 1.000). For predicting preeclampsia, the mean uterine artery RI had to be >0.7 having sensitivity (60%), specificity (97.03%), PPV (75%) and NPV (94.23%). The area under curve (AUC) was 0.856 (95% CI, 0.742 - 0.971).Conclusions: Second trimester UA doppler is a useful screening test for prediction of preeclampsia. This test works best when combined with a spot UPCR and accuracy of both the methods for prediction of preeclampsia was 92.24%

Uterine Artery Doppler Velocimetry During Mid-second Trimester to Predict Complications of Pregnancy Based on Unilateral or Bilateral Abnormalities

We performed this study to evaluate uterine artery Doppler velocimetry (UADV) measurement of unilateral or bilateral abnormalities as a predictor of complications in pregnancy during the mid-second trimester (20-24 weeks). We enrolled 1,090 pregnant women who had undergone UADV twice: once between the 20th and 24th week (1st stage) and again between the 28th and 32nd week (2nd stage) of pregnancy, and then delivered at Yonsei Medical Center. UADV was performed bilaterally. Follow-up UADV was performed between the 28th and 32nd week, and the frequencies of pregnancy-induced hypertension (PIH), fetal growth restriction (FGR), and preterm delivery (before 34 weeks of gestation) were determined. Chi-squared and t-tests were used where appropriate, with p < .05 considered significant. According to the results of UADV performed between 20-24 weeks of gestation, 825 women (75.7%) were included in the normal group, 196 (18.0%) in the unilateral abnormality group, and 69 (6.3%) in the bilateral abnormality group. The incidences of FGR were 8.0%, 10.2%, and 26.1%, and the incidences of PIH were 0.1%, 3.6%, and 14.5%, respectively. The incidence of PIH was significantly lower in the normal group. The incidences of preterm delivery were 2.2%, 5.6%, and 8.7%, respectively. PIH developed in 46.7% of patients with bilateral abnormal findings in both the 1st and 2nd stage tests, and developed in none of the patients with normal findings in both tests. Abnormal results found by UADV performed between the 20-24th weeks of pregnancy, such as high S/D ratios regardless of placental location and the presence of an early diastolic notch, were associated with significant increases in the incidences of intrauterine growth restriction (IUGR) and PIH. This was true for both bilateral and unilateral abnormalities. Abnormal findings in bilateral UADV during the second trimester especially warrant close follow up for the detection of subsequent development of pregnancy complications

Uterine artery Doppler velocimetry and obstetric outcomes in connective tissue diseases diagnosed during the first trimester of pregnancy.

OBJECTIVE: To evaluate the effect of connective tissue disease (CTD) diagnosed during the first trimester on uterine arteries (UtA) Doppler velocities and on pregnancy outcomes. METHOD: Pregnant women were screened for CTDs during the first trimester, using a questionnaire, testing for autoantibodies, rheumatologic examination and UtA Doppler evaluations. RESULTS: Out of 3932 women screened, 491 (12.5%) were screened positive at the questionnaire; of them, 165(33.6%) tested positive for autoantibodies, including 66 eventually diagnosed with undifferentiated connective tissue disease (UCTD), 28 with a definite CTD and 71 with insufficient criteria for a diagnosis. Controls were 326 women screened negative for autoantibodies. In logistic analysis, women diagnosed with either UCTD (OR = 7.9, 95% CI = 2.3-27.3) or overt CTD (OR = 24.9, 95% CI = 6.7-92.4), had increased rates of first trimester bilateral UtA notches compared with controls. The rates of bilateral UtA notches persisting in the second (15/94 vs 0/326, p < 0.001) and third trimesters (7/94 vs 0/326, p < .001) were higher among women with CTDs than in controls. The risk of complications (preeclampsia, fetal growth restriction, prematurity, diabetes, fetal loss) was higher (OR = 7.8, 95% CI = 3.6-17.0) among women with CTDs than in controls. CONCLUSION: Women with undiagnosed CTDs have higher rates of bilateral UtA Doppler notches throughout pregnancy and increased rates of adverse pregnancy outcomes than controls

Serum Beta HCG and uterine artery Doppler studies in second trimester to predict preeclampsia and eclampsia

Background: Hypertensive disorders during pregnancy remain amongst the most significant and intriguing unsolved problems in obstetrics. The study aims at testing the hypothesis that women with high serum beta hCG levels and alterations in waveforms in the uterine artery doppler in early second trimester have high risk of developing pre-eclampsia.Methods: Serum Beta hCG estimation was done by Sandwich chemiluminescence immunoassay method. All uterine artery waveforms were obtained using a Toshiba nemio ultrasound machine attached to a 3.5 MHz curvilinear transducer, with colour and pulsed Doppler abilities.Results: For prediction of preeclampsia or eclampsia uterine artery Doppler velocimetry alone shows specificity of 96.30%, sensitivity of 90%, positive predictive value of 94% and negative predictive value of 80%. When it is combined with serum beta HCG sensitivity and specificity are almost same, but alone serum beta HCG levels are showing sensitivity of 96% and specificity of just 76%.Conclusions: Abnormal waveforms on uterine Doppler studies are the better predictors for preeclampsia and eclampsia when done in early second trimester

Ophthalmic artery Doppler for prediction of pre‐eclampsia: systematic review and meta‐analysis

Objective To determine the accuracy of ophthalmic artery Doppler in pregnancy for the prediction of pre‐eclampsia (PE). Methods MEDLINE, EMBASE, CINAHL and The Cochrane Library were searched for relevant citations without language restrictions. Two reviewers independently selected studies that evaluated the accuracy of ophthalmic artery Doppler to predict the development of PE and extracted data to construct 2 × 2 tables. Individual patient data were obtained from the authors if available. A bivariate random‐effects model was used for the quantitative synthesis of data. Logistic regression analysis was employed to generate receiver–operating characteristics (ROC) curves and obtain optimal cut‐offs for each investigated parameter, and a bivariate analysis was employed using predetermined cut‐offs to obtain sensitivity and specificity values and generate summary ROC curves. Results A total of 87 citations matched the search criteria of which three studies, involving 1119 pregnancies, were included in the analysis. All included studies had clear description of the index and reference tests, avoidance of verification bias and adequate follow‐up. Individual patient data were obtained for all three included studies. First diastolic peak velocity of ophthalmic artery Doppler at a cut‐off of 23.3 cm/s showed modest sensitivity (61.0%; 95% CI, 44.2–76.1%) and specificity (73.2%; 95% CI, 66.9–78.7%) for the prediction of early‐onset PE (area under the ROC curve (AUC), 0.68; 95% CI, 0.61–0.76). The first diastolic peak velocity had a much lower sensitivity (39.0%; 95% CI, 20.6–61.0%), a similar specificity (73.2%; 95% CI, 66.9–78.7%) and a lower AUC (0.58; CI, 0.52–0.65) for the prediction of late‐onset PE. The pulsatility index of the ophthalmic artery did not show a clinically useful sensitivity or specificity at any cut‐off for early‐ or late‐onset PE. Peak ratio above 0.65 showed a similar diagnostic accuracy to that of the first diastolic peak velocity with an AUC of 0.67 (95% CI, 0.58–0.77) for early‐onset PE and 0.57 (95% CI, 0.51–0.63) for late‐onset disease. Conclusions Ophthalmic artery Doppler is a simple, accurate and objective technique with a standalone predictive value for the development of early‐onset PE equivalent to that of uterine artery Doppler evaluation. The relationship between ophthalmic Doppler indices and PE cannot be a consequence of trophoblast invasion and may be related to maternal hemodynamic adaptation to pregnancy. The findings of this review justify efforts to elucidate the effectiveness and underlying mechanism whereby two seemingly unrelated maternal vessels can be used for the prediction of a disease considered a ‘placental disorder’

Study of fetomaternal arterial doppler parameters in early onset pre-eclampsia and its correlation with perinatal outcomes

Background: Development of pre-eclampsia (PE) at less than 34 weeks of gestation is known as early onset PE (EOPE) and is commonly associated with more severe adverse maternal and fetal outcomes. The purpose of this study was to study Doppler parameters of uterine, umbilical and fetal middle cerebral arteries exclusively in women with EOPE and its correlation with perinatal outcomes. This study was a hospital-based observational prospective study.Methods: 60 patient of early onset PE with singleton live pregnancy were included in the study and followed up. The results of sonographic and Doppler examination were analysed and correlated with perinatal outcomes.Results: Adverse perinatal outcomes were seen in 66.66% cases of early onset PE. To predict adverse perinatal outcomes, umbilical artery (Umb A) RI, PI were found to be most sensitive, cerebroplacental ratio (CPR) was most specific indicator with highest positive predictive value (PPV). Absent end diastolic flow /reverse end diastolic flow (AEDF/REDF) were ominous signs.Conclusions: Early onset PE is recently considered a more severe disease with different etiopathogenesis. Doppler study is the primary imaging modality for fetomaternal surveillance for follow up and prediction of perinatal outcome, thus allowing planning of timely management in early onset PE patients, as these patients are at higher risk of adverse perinatal outcomes

A Prospective Study of Doppler Velocimetry in Pregnancy-induced Hypertension in a Rural Population of a Developing Country

Background: Pregnancy-induced hypertension (PIH) remains a great challenge to obstetricians. Doppler velocimetry can detect fetal compromise much before other antepartum tests.Aim: The aim of this study is to detect the changes of uterine artery, umbilical artery and middle cerebral artery in PIH by Doppler velocimetry.Subjects and Methods: This prospective study was conducted on hundred subjects with PIH. Doppler studies were carried, and parameters recorded in uterine, umbilical and middle cerebral artery (MCA) were Systolic/Diastolic ratio, Resistance Index, Cerebro Placental Index (CPI). Fetal outcomes were monitored. Statistical analysis was performed using Epi InfoTM software (Version 3.5.1, CDC, Atlanta). Test for significance was done with student’s t-test and Chi-square where applicable. A P- value of&lt;0.05 was considered as significant.Results: Among the 100 subjects, 76 (76%) of fetuses had abnormal and 24% normal umbilical artery Doppler velocimetry; 62% had abnormal and 38% normal MCA Doppler velocimetry; 64% fetuses had abnormal and 36% normal CPI. In 95% of subjects having abnormal umbilical Doppler studies, caesarean section had to be done for acute fetal distress. Incidence of caesarean section was 61% in abnormal MCA group and 63% in abnormal CPI group. Among 14 patients who had abnormal uterine artery Doppler, four developed pre-eclampsia, 2 IUGR. In patients with notches in uterine artery Doppler, 38% developed pre-eclampsia, 38% had IUGR, 13% babies were still born and 25% of newborns required NICU admission. In umbilical artery Doppler, when S/D ratio was abnormal, 60% developed pre-eclampsia, 40% had IUGR and 40% of newborns had to be admitted in NICU.Conclusion: Doppler study for fetal surveillance in pregnancy-induced hypertension is a very useful device and abnormal umbilical artery and uterine artery velocimetry seems to have worse pregnancy outcomes in the present study. Notch as a single parameter is the best indicator with highest sensitivity and positive predicative values. However, combination of parameters is the best indicator.  Keywords: Doppler study, fetomaternal outcome, pregnancy-induced hypertensio