RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
SYNOPSIS
OF
DISSERTATION
"COLOUR DOPPLER STUDY OF FETOMATERNAL CIRCULATION IN HYPERTENSIVE DISORDERS
OF PREGNANCY AND OLIGOHYDRAMNIOS
IN THIRD TRIMESTER
AND ITS PERINATAL OUTCOME"
Submitted by
Dr. BHAVANA. S
M.B.B.S.
POST GRADUATE STUDENT IN
OBSTETRICS AND GYNAECOLOGY (M.S)
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,
B.G.NAGARA-571448
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS
(in block letters) / Dr. BHAVANA. S
P.G IN OBSTETRICS & GYNAECOLOGY,
ADICHUNCHUNAGIRI INSTITUTE OF
MEDICAL SCIENCES.B.G NAGARA,
MANDYA DISTRICT -571448
2. / NAME OF THE INSTITUTION /
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G.NAGARA.3. / COURSE OF STUDY AND SUBJECT /
M.S. IN OBSTETRICS & GYNAECOLOGY
4. / DATE OF ADMISSION TO COURSE / 8th JUNE 20125. / TITLE OF THE TOPIC / COLOUR DOPPLER STUDY OF FETOMATERNAL CIRCULATION IN HYPERTENSIVE DISORDERS OF PREGNANCY AND OLIGOHYDRAMNIOS IN THIRD TRIMESTER AND ITS PERINATAL OUTCOME
6. / BRIEF RESUME OF INTENDED WORK
6.1 NEED FOR THE STUDY
6.2 REVIEW OF LITERATURE
6.3 OBJECTIVES OF THE STUDY / APPENDIX-I
APPENDIX-IA
APPENDIX-IB
APPENDIX-IC
7 / MATERIALS AND METHODS7.1 SOURCE OF DATA
7.2 METHOD OF COLLECTION OF DATA : (INCLUDING SAMPLING PROCEDURE IF ANY)
7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER ANIMALS, IF SO PLEASE DESCRIBE BRIEFLY.
7.4 HAS ETHICAL CLEARENCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3 / APPENDIX-II
APPENDIX-IIA
APPENDIX-IIB
YES
APPENDIX-IIC
YES
APPENDIX-IID8. / LIST OF REFERENCES /
APPENDIX – III
9. / SIGNATURE OF THE CANDIDATE /10. /
REMARKS OF THE GUIDE
/ Colour doppler study in pregnancy with oligohydramnios is going to help in diagnosis of fetal condition and to take early intervention to reduce perinatal mortality and morbidity11 / NAME AND DESIGNATION
(in Block Letters)
11.1 GUIDE / Dr. GOPAL. N., M.D., D.G.O
Professor,
Department of Obstetrics and Gynecology,
AIMS, B.G. Nagara-571448
11.2 SIGNATURE OF THE GUIDE
11.3 CO-GUIDE (IF ANY) / Dr. MALLIKARJUNAPPA
Associate Professor,
Department of Radiology,
AIMS, B.G. Nagara-571448
11.4 SIGNATURE
11.5 HEAD OF DEPARTMENT / Dr. S. VIJAYALAKSHMI, M.D, D.G.O
Professor and Head
Department of Obstetrics and Gynaecology
AIMS, B.G. Nagara-57144811.6 SIGNATURE
12 / 12.1 REMARKS OF THE CHAIRMAN
AND PRINCIPAL / The facilities required for the investigation will be made available by the college
Dr. M.G. SHIVARAMU, M.B.B.S, M.D.
PRINCIPAL,
AIMS, B.G. NAGARA.
12.2 SIGNATURE
APPENDIX-I
6. BRIEF RESUME OF THE INTENDED WORK:
APPENDIX-1A
INTRODUCTION:
Diagnostic ultrasound in the 21st century has provided a newer horizon in the imaging modality and is useful for detection and management of obstetric cases which in turn is useful in decreasing perinatal mortality and morbidity.
Doppler is considered to be the best tool in investigating and assessing accurate changes in Fetomaternal circulation and to predict perinatal outcome so as to take decision for appropriate intervention.
The availability of colour Doppler facility in our institute Adichunchanagiri Institute of Medical Sciences, facilitated the study of role of colour Doppler evaluation of Fetomaternal circulation in hypertensive disorders of pregnancy and oligohydramnios.
6.1 NEED FOR THE STUDY
Hypertensive disorders of pregnancy is one of the most common complication that effects the mother.
It is one of the leading cause of maternal and fetal mortality and morbidity.
The traditional methods of fetal surveillance like NST, fetal heart monitoring, fetal BPP are no more ideal tests because of their inability to detect early stages of fetal distress.
Doppler technique has been applied to investigate the fetal, fetoplacental, uteroplacental circulation, as it is a noninvasive technique and has a diagnostic and prognostic evaluation.
APPENDIX –I B
6.2 REVIEW OF LITERATURE
Hypertensive disorders of pregnancy are among the commonest medical disorders during pregnancy and continue to be the major cause of maternal and perinatal mortality and morbidity worldwide.
Hypertension during pregnancy is defined as a sustained systolic blood pressure of 140mm Hg or more and/or a diastolic blood pressure of 90mmHg or more. This is best confirmed when evidence is present on 2 occasions at least 6 hours apart but within 7 days.
Proteinuria is defined as excretion of ≥0.3g protein in a 24 hour sample which correlates with ≥30mg/dl or >1+ on dipstick in a random sample after excluding urinary tract infection.
In developing countries they rank 2nd only to anaemia with approximately 7-10% of all the pregnancies being complicated by some form of hypertensive disease.1
According to the NHBPEP-National High Blood Pressure Education Program (2000). Hypertensive disorders of pregnancy are classified into 4 types:2
1. Gestational Hypertension: Hypertension 1st diagnosed after 20 weeks gestation not accompanied by proteinuria.
2. Pre-eclampsia – Eclampsia: Hypertension 1st diagnosed after 20 weeks gestation accompanied by proteinuria; Eclampsia if seizures occur.
3. Chronic Hypertension: Hypertension present before pregnancy or 1st diagnosed before 20weeks gestation.
4. Pre-eclampsia superimposed on chronic hypertension.
Pre-eclampsia complicates 2-8% of all pregnancies and a major cause of maternal morbidity, perinatal death and premature delivery.
Risk factors:
· Nulliparity
· Extremes of age: more in women younger than 20 years of age.
· Obstetric factors:-pre-eclampsia in previous pregnancy.3
- Multiple gestation
- Hydrops fetalis
- Hydatidiform mole
- Abnormal uterine Doppler flow at 18-24 weeks
· Genetic –family history of pre-eclampsia
· Pre-existing medical disorders-hypertension
- Diabetes mellitus
- Renal disease
- Autoimmune disease
Pre-eclampsia and IUGR are associated with an inadequate quality and quantity of the maternal vascular response to placentation. Placental bed biopsies from pregnancies complicated with this showed absence of physiological changes in spiral arteries beyond the decidual- myometrial junction in more than 80% of cases. Few necrotizing lesion with foam cells in the wall of the basal and spiral arteries referred as acute atherosis.4
Complications:
The most common maternal complications was eclampsia, followed by cerebrovascular accidents, abruption placenta, HELLP syndrome, acute left ventricular failure with pulmonary edema, acute renal failure and microangiopathic anemia.
Fetal complications were IUGR, prematurity and its associated complications, birth asphyxia and IUD.
The categories in this classification are easily distinguished by careful history, physical examination, laboratory investigations – complete blood count including platelet count, liver function tests, urine analysis, urine culture, serum uric acid, blood urea, serum creatinine and 24 hour urine evaluation for protein excretion and antenatal fetal monitoring-daily fetal kick count/biweekly NST and ultrasonography for evaluation of fetal growth, BPP, AFI, cardiotocography and umbilical artery flow velocimetry.
Treatment includes rest, diet, control of BP-antihypertensives and obstetric management. In Eclampsia-treatment includes control of BP and control of seizures-anticonvulsants and sedative regimens, treatment of complications and delivery. Termination of pregnancy is the only definitive treatment for pre-eclampsia and eclampsia.
Doppler flow studies are an important adjunct to fetal biometry in identifying the fetus at risk of adverse outcome. Placental insufficiency is the primary cause of IUGR in normally formed fetuses and can be identified using umbilical artery Doppler velocimetry.5,6,7
The most widely used arterial indicies are pulsality index, systolic/diastolic ratio, resistance index.
· PI-systolic end diastolic peak velocity/time averaged maximum velocity.
· RI-systolic end diastolic peak velocity/systolic peak velocity.
· S/D ratio-systolic peak velocity/diastolic peak velocity.
The essential vessels to be examined include the umbilical artery, MCA. As the vascular impedence in the placenta increases, fetal protective mechanisms are triggered which are reflected in Doppler studies.
1. The umbilical artery
S/D ratio at 28 weeks of gestation is 3 + 0.6 and at 30 weeks it is reduced to 2.5 + 0.4. A S/D ratio > 4 is considered abnormal.
R1 at 28 weeks is 1.3 + 0.5 and 30 weeks is 1 + 0.4.
2. Uterine artery
During course of pregnancy the uterine artery changes from a high resistance pattern with notches to a low resistance pattern with no notches.
Disappearance of notch will happen first in the uterine artery, which is directly under the placenta. Normally the notch is seen until 24 weeks of gestation, persistence of notch after 26 weeks is an indication of hypertensive complications / IUGR / both.
Upperlimit of S/D Ratio is 2.6, if > 2.6 after 26 weeks suggest adverse outcome upperlimit of RI – 0.68.
3. MCA à Mean PI at 28 weeks is 1.6 + 0.4 and at 40 weeks 1.2 + 0.4.
Doppler ultrasound staging guidelines for intrauterine growth restriction:
Stage 1:
· Abnormal umbilical artery PI
· Abnormal MCA PI.
Stage 2:
· Umbilical artery absent/reversed flow.
· Elevated MCA peak systolic velocity.
· Abnormal DV PI ,umbilical vein pulsation
Stage 3:
· DV reversed flow.
· Umbilical vein reversed flow.
· Tricuspid valve E/A ratio>1
Risk of perinatal mortality increases up to 60%with increasing severity from reduced to reversed end diastolic flow velocity.
Therefore in presence of reversal of diastolic flow in umbilical artery, delivery by cesarean section may be considered if fetal viability is achieved.
This decision is influenced by EFW, gestational age, Doppler parameters, assessements of fetal health.
Oligohydramnios as defined by Phelan8 as AFI <5 cm but Jeng9 et al proposed a cut off of 8 cm demonstrating increased incidence of meconium staining, cesarean delivery for fetal distress. Abnormal fetal heart rate pattern and apgar score of 7/less at one minute when AFI was < 8. Increased perinatal mortality can be largely explained by the high risk conditions associated with it like IUGR, hypertension, premature rupture of membranes and postmaturity.
Oligohydramnios is a condition where the liquor amnii is deficient in amount to the extent of less than 200 ml at term. About 8% of pregnant women can have low levels of fluid, with about 4% being diagnosed with oligohydramnios. Amniotic fluid can be measured by a few different methods, most commonly through amniotic fluid index (AFI) evaluation or deep pocket measurements. If an AFI shows a fluid level of less than 5 centimeters (or less than the 5th percentile) the absence of a fluid pocket 2-3 cms in depth or a fluid volume of less than 500 ml at 32-36 weeks of gestation, then a diagnosis of oligohydramnios would be suspected.10
Doppler velocimetry of the umbilical artery must be performed and the S/D ratio recorded. An increased S/D ratio in cases of oligohydramnios helps to identify fetuses at risk 80% of fetuses had an adverse perinatal outcome when umbilical artery Doppler was abnormal in study.
According to C.J. Bhat et al in a study of 100 hypertensive patients 56% had abnormal s/d ratio in umbilical artery / uterine artery.60% of these delivered IUGR babies.
The results of abnormal umbilical artery were more significant than uterine artery in predicting perinatal outcome.11
Qntani et al proposed increased diastolic flow velocity in MCA fetal compensation to the uteroplacental insufficiency in IUGR fetuses, trends of MCA-PI and MCA-PSV provide more clinical information than do 1 measurement. A high MCA-PSV predicts perinatal mortality better than does a low MCA-PI.12
Khalid et al –in a study, 34 out of 36 hypertensive patients abnormal uterine artery flow of which 11 had IUGR and 1 had IUD as fetal outcome.28 patients showed brain sparing effect with reduced value of indices in fetal MCA.13
APPENDIX –IC
6.3 AIMS AND OBJECTIVES OF STUDY
1. The aim of the study is to evaluate and study the Fetomaternal circulation using colour Doppler in hypertensive disorders of pregnancy and oligohydramnios in third trimester so that we may predict various complications that may arise because of the above mentioned and to follow the fetal outcome.
2. To intervene timely.
3. To plan the treatment and council the patient regarding perinatal outcome.
APPENDIX-II
7.0 MATERIALS AND METHODS
APPENDIX-II A
7.1 SOURCE OF DATA
This study will be carried out in the department of Obstetrics and Gynaecology, Sri Adichunchanagiri Institute of Medical Sciences, B.G. Nagara, in pregnant women attending OPD /admitted and satisfying the inclusion and exclusion criteria during the period November 2012 to October 2014.
Study Design : A prospective case control study
Study Period : 24 Months (November 2012 to October 2014)
APPENDIX-II B
7.2 METHOD OF COLLECTION OF DATA
INCLUSION CRITERIA
Color Doppler study in pregnant women with
1. Hypertensive disorders of pregnancy
· Gestational hypertension.
· Pre eclampsia
· Eclampsia
2. Oligohydramnios : AFI < 5 cm
3. Estimated fetal weight < 10th percentile for gestational age
EXCLUSION CRITERIA
· Chronic renal diseases
· Severe malnutrition
· Chronic hypertension
· Hypertension due to other causes like vascular, endocrinal, neurogenic.
· Symmetrical IUGR-due to genetic causes and infection, chromosomal disorders occurring in 1st trimester.
Statistical Analysis Done by :
Appropriate statistical methods proposed for the study will be applied.
APPENDIX-II C
7.3 Does the study require any investigation or intervention to be conducted on the patients or animals , if so please describe briefly
YES
Investigation :
FOR MOTHER
· HEMATOLOGICAL: Hemoglobin, Total Leukocyte count, differential count, platelet count, bleeding time, clotting time and peripheral blood smear.
· BIOCHEMISTRY: Blood Urea, serum creatinine, serum uric acid, LFT (SGOT, SGPT, Alkaline Phosphatase, Total protein, Albumin, Globulin, Bilirubin-total and direct), Electrolytes and Fasting blood sugar.
· URINE ANALYSIS: Urine routine and microscopic examination and 24 hour urine for protein.
· RADIOLOGIC: ultrasonic assessment for the fetal weight, AFI, BPP, placental location and maturity
· NON STRESS TEST
· FUNDOSCOPY
· Colour Doppler study –PI, RI, S/D RATIO
· OTHER INVESTIGATIONS: Carried out as and when required.
In patients with chronic hypertension, further investigations to ascertain the cause of hypertension. Doppler study and spiral CT Angiography in selected cases. In suspected coagulation disorder-bleeding time, clotting time, prothrombin time, aPTT and serum fibrinogen. In patients with Encephalopathy, CT scans of the cranium.