RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF DISSERTATION
TOPIC
“DOPPLER VELOCIMETRY OF UMBILICAL AND MIDDLE CEREBRAL ARTERIES IN HIGH RISK PREGNANCIES IN THE PREDICTION OF FETAL OUTCOME”
DR. JATHIN KRISHNA RAI. K.
POSTGRADUATE
DEPT OF RADIO DIAGNOSIS & IMAGING
K.S.HEGDE MEDICAL ACADEMY
DERLAKATTE, MANGALORE-575018.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / DR. JATHIN KRISHNA RAI. K.DEPT OF RADIO DIAGNOSIS
& IMAGING
K.S.HEGDE MEDICAL ACADEMY
DERLAKATTE, MANGALORE-575018.
2 / NAME OF THE INSTITUTION / K.S.HEGDE MEDICAL ACADEMY
DERLAKATTE, MANGALORE-575018
3 / COURSE OF STUDY AND SUBJECT / M.D. (RADIO DIAGNOSIS)
4 / YEAR OF JOINING THE COURSE / MAY 2008.
5 / TITLE OF THE TOPIC / DOPPLER VELOCIMETRY OF UMBILICAL AND MIDDLE CEREBRAL ARTERIES IN HIGH RISK PREGNANCIES IN THE PREDICTION OF FETAL OUTCOME.
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BRIEF RESUME OF INTENDED WORK
NEED FOR THE STUDY
Antepartum foetal surveillance is the corner stone of management aimed at reducing perinatal mortality and morbidity. Ultrasound has revolutionized the antepartum fetal assessment as a whole.
The incorporation of Doppler derived haemodynamic information into the standard anatomic sonographic assessment allows the additional evaluation of a variety of physiologic parameters in obstetrics and gynecology, previously out of reach to the sonographer and sonologist.
The Doppler Velocimetry of the foetoplacental circulation can be used to further investigate such complications of pregnancy as foetal growth restriction and other forms of foetal distress that result from foetal hypoxemia or asphyxia and foetal cardiac anomalies 1, 2, 3.
REVIEW OF LITERATURE
According to the study done by Guerrero Casillas MA, Romero Gutierrez G, Molina Rodriguez R, Guzan Mena G4, on 161 patients with high risk pregnancies. They concluded that a correlation between middle cerebral artery/ umbilical artery resistance index and non stress test. The index had more sensitivity and specificity for diagnosing perinatal death and APGAR score.
According to the study done by Hugo EJ, Odendaal HJ, Grove D5 on pregnant women suspected poor fetal growth a normal flow velocity wave forms of the umbilical artery is less likely to be followed by perinatal death.
According to the study done by Habek D, Salihagic A, Jugovic D, Herman R6, on 58 pregnant women wth pregnancy from 28-42 weeks of gestation with late IUGR , concluded that cerebro- umbilical ratio and foetal biophysical profile monitoring is needed in perinatal monitoring of growth retarded foetuses and deciding to end pregnancies with IUGR.
According to the study done by BN Lakhkar, KV Rajgopal, PT Gourisankar7, on 58 Singleton pregnancies beyond 30 weeks of gestation complicated by IUGR and Pre- eclampsia it was concluded that Doppler studies of multiple vessels in the fetoplacental circulation can help in the monitoring of compromised fetuses and help to predict neonatal morbidity.
According to the study done by Malhotra Neena, Chanana Charu, Kumar Sunesh, Roy Kallol, Sharma JB8 on 70 pregnant women with growth restricted fetuses it was concluded that umbilical artery Doppler should be used in the management of growth restricted fetuses.
According to the study conducted by Ebrashy A, Azmy O, Ibrahim M, Waly M, Edris A9, on 50 pregnant women with pre eclampsia with or without IUGR, it was found that there was a strong correlation between the middle cerebral /umbilical artery RI and neonatal outcome in women with preeclampsia.
Cosmi E, Ambrosini G, D’Antona D, Saccardi C, Mari G. Vergani P, Roncaglia N et al 10 conducted a study on 145 singleton growth restricted fetuses with abnormal umbilical artery pulsatility indices and found that it was associated with increased perinatal mortality and morbidity.
According to the study conducted by Marek Szymanski, Wieslaw Szymanski, Mariusz Semenczuk, Stanislaw Skublicki 11 on 150 pregnant ladies it was concluded that Doppler investigation by measure of parameter of blood flow in umbilical cord artery ( PI , RI, S/D ) can be predictive of fetal threat and useful in estimation of new born state .
According to the study conducted by Serap Yalti, Ozay Oral, Birgul Gurbuz, Secuz Ozden & Feyruz Atar12, on 50 preeclamptic pregnant women it was found that the middle cerebral artery/ umbilical artery was valuable for predicting the outcome of preeclamptic and Hypertensive pregnancies.
Another study conducted by Soregaroli M, Bonera R, Danti L, Dinolfo D, Taddei F, Valcamonico A et al13, 578 pregnancies with IUGR a strict correlation was found between abnormal umbilical Doppler velocimetry and increased incidence of perinatal complications.
According to the study done by Baschat AA, Gembruch U, Viscardi RM, Gortner L, and Harman CR 14 on 113 growth restricted fetuses who delivered prematurely they concluded that loss of umbilical artery end diastolic velocity early in gestation significantly increases the risk for intraventricular hemorrhage and prematurity.
The study done by Severi FM, Boochi C, Visentin A, Falco P, Cobellis L, Florio P et al 15 on 231 pregnancies , it was found that SGA fetuses with both uterine and fetal cerebral waveforms altered at the same time the risk of fetal distress is exceedingly high (86%) compared to those with both vessels having normal waveforms(4%).
According to the study done by Johnson P, Stojilkovic T, Sarkar P 16 on 18 normal singleton pregnancies with suspected IUGR, it was found that difference in the pattern of change in middle cerebral artery pulsatility index in IUGR fetuses reflected the degree of fetal compromise.
According to the study done by Schwarze A, Nelles I, Krapp M, Friedrich M, Schmidt W, Diedrich K et al 17 on 346 pregnant patients, abnormal uterine artery Doppler studies at 23-26 weeks of gestation increases the predictive value for adverse pregnancy outcomes.
The study conducted by Makhseed M, Jirous J, Ahmed MA, Vishwanathan DL18, on fetuses that were small for their gestational age in 70 pregnancies it was found that Middle cerebral artery/ umbilical artery ratio is a good predictor of neonatal outcome and could be used to identify fetuses at risk of morbidity and mortality.
According to the study conducted by Teixeira JM, Duncan K, Letsky E, Fisk NM19, on 26 alloimmunized fetuses, before their first foetal blood transfusion it was found that Middle cerebral artery peak systolic velocity is a useful test in clinical practice for the detection of foetal anaemia.
According to the study conducted by M.Makhseed, J.Jirous, M.A.Ahmed and D.L.Viswanathan20, in 70 singleton pregnancies with fetuses that were small for gestational age, concluded that Middle cerebral artery/ Umbilical artery ratio is a good prediction of neonatal outcome and could be used to identify foetuses at risk of morbidity and mortality.
According to the study done by Pere-Joan Torres ; Eduard Gratacos ; Pedro L. Alonso21, on 172 hypertensive pregnant women it was concluded that umbilical artery Doppler velocimetry is a useful tool to assess fetal well being in hypertensive pregnancies.
OBJECTIVES OF THE STUDY
1. To study the Systolic/ Diastolic ratio (S/D ratio) , pulsatility index (PI) and resistance index (RI) of umbilical artery and middle cerebral arteries in high risk pregnancies.
2. Ratio of middle cerebral to umbilical artery blood velocity in high risk pregnancies.
3. To evaluate the role of these blood flow indices in the prediction of adverse foetal outcome.
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MATERIALS AND METHODS
SOURCE OF DATA
The study will be done on a total of 50 pregnant women with high risk factors in the III trimester after 30 weeks till term, undergoing Doppler Velocimetry of umbilical and middle cerebral arteries in the department of Radio Diagnosis and Imaging in Justice K.S Hegde Medical Academy during November 2008 to November 2010.
Criteria for Inclusion in the Study
1. Well documented length of pregnancy
2. Singleton pregnancy
3. Gestational age beyond 30 weeks.
4. High risk factors considered
i) Pre eclampsia
ii) Intra Uterine Growth Restriction
iii) Gestational diabetes mellitus
iv) Anemia
v) Previous Ceaserean section
vi) Bad obstetric history
vii) Rh isoimmunisation
viii) Twin pregnancy
ix) Fetal congenital anomalies
Criteria for exclusion in the study
1. Threatened preterm labour
2. Wrong dates
ABNORMAL PERINATAL OUTCOME
The perinatal outcome will be considered abnormal when any one or combinations of the following are present.
1. Perintatal death
2. Thick meconium stained liquor
3. Apgar < 7 at 5 minutes
4. Respiratory complications within 72 hours of birth
5. NICU admission within 72 hours of birth.
METHOD OF COLLECTION OF DATA
Doppler velocity waveforms of umbilical and middle cerebral arteries will be taken for high risk pregnancies.
A colour Doppler ultrasound apparatus (LOGIC 400 PRO-GE series) equipped with 3.75 MHz transducer will be used for the Doppler study.
All the examinations will be made with the patient lying in semi recumbent position with a lateral tilt. Doppler transducer will be placed on the abdominal wall over the uterus and carefully manipulated till Doppler signals appropriate for those particular vessels are identified. All the examinations will be performed only during foetal apnoea and foetal inactivity.
The signal will be recorded for a minimum of 5 to 8 cycles with blood flow velocity waveforms of equal shape and amplitude and satisfactory quality. Then the image will be frozen and measurements will be taken.
Normal values of Doppler Velocimetry [ 30th week – 40th week of pregnancy ] :
1. Umbilical artery :
S/D ratio : < 3 , P.I. : 0.7 – 1.4 , R.I. : 0.5 – 0.7
2. Middle Cerebral Artery :
S/D ratio : > 4 , P.I. : > 1.3 , R.I. : 0.7
*(S/D = maximum peak Systolic frequency / end – Diastolic velocity
P.I. = Pulsatility index
R.I. = Resistance Index) 1, 2, 3.
3. Ratio of Middle Cerebral Artery RI / Umbilical Artery RI 1
*(Middle Cerebral Artery RI Normal is 0.7
Umbilical Artery RI Normal is 0.5 – 0.7) 1, 2, 3.
LIST OF REFERENCES
1. Tekay A, Campbell S. Doppler Ultrasonography in Obstetrics. In: Callen PW, editor. Ultrasonography in Obstetrics and Gynaecology. 4th ed. Philadelphia: Saunders; 2000. p. 677-717.
2. Nicholson S, Nimrod C. Doppler Assesment of Pregnancy. In: Rumack CM, Wilson SR, Charboneau JW, editors. Diagnostic Ultrasound. 1st ed. St. Louis: Mosby; 1991. p. 955-68.
3. Seshadri S, Rao K. Clinical Practice Fetal Doppler. Asian Journal of OBS and Gynae Practice. August 2003; Vol.7, No.7: 17-22.
4. Guerrero Casillas MA, Romero Gutierrez G, Molina Rodriguez R, Guzan Mena G. Correlation between Doppler fluxometry of middle cerebral artery/umbilical and non stress test as methods of antepartum fetal surveillance. Ginecol Obstet Mex. 2007 Apr; 75(4):193-9.
5. Hugo EJ, Odendaal HJ, Grove D. Evaluation of the use of umbilical artery Doppler flow studies and outcome of pregnancies at a secondary hospital. J Matern Fetal Neonatal Med. 2007 Mar; 20(3):233-9.
6. Habek D, Salihagic A, Jugovic D, Herman R. Doppler cerebro-umbilical ratio and fetal biophysical profile in the assessment of peripartal cardiotocography in growth-retarded fetuses. Fetal Diagn Ther. 2007; 22(6):452-6. Epub 2007 Jul 24.
7. BN Lakhkar, KV Rajgopal, PT Gourisankar . Doppler prediction of adverse perinatal outcome in PIH and IUGR. Indian J Radiol Imaging 2006; 16:109-116.
8. Malhotra Neena, Chanana Charu, Kumar Sunesh, Roy Kallol, Sharma JB. Comparison of Perinatal outcome of Growth-Restricted Fetuse with normal and abnormal Umbilical Artery Doppler waveforms. Indian Journal of Medical Sciences, Vol. 60, No. 8, August, 2006, pp. 311-317.
9. Ebrashy A, Azmy O, Ibrahim M, Waly M, Edris A. Middle cerebral/ umbilical artery resistance index ratio as sensitive parameter for fetal well being and neonatal outcome in patients with preeclampsia: case-control study. Croat Med J. 2005 Oct; 46(5):821-5.
10.Cosmi E, Ambrosini G, D’Antona D, Saccardi C, Mari G. Vergani P, Roncaglia N et al. Doppler, cardiotocography , and biophysical profile changes in growth-restricted fetuses. Obstet Gynecol. 2005 Dec; 106(6): 1240-5.
11. Marek Szymanski, Wieslaw Szymanski, Mariusz Semenczuk, Stanislaw Skublicki. Relationship between Doppler velocimetry at maddle cerebral artery and umbilical artery and status of newborn after delivery. Ginekol Pol. 2005 Sep; 76 (9):713-9 16417083.
12. Serap Yalti, Ozay Oral, Birgul Gurbuz, Secuz Ozden & Feyruz Atar. Ratio of middle cerebral to umbilical artery blood velocity in preeclamptic & hypertensive women in the prediction of poor perinatal outcome. Indian J Med Res 120, July 2004,pp44-50.
13.Soregaroli M, Bonera R, Danti L, Dinolfo D, Taddei F, Valcamonico A et al. Prognostic role of umbilical artery Doppler velocimetry in growth-restricted fetuses. J Matern Fetal Neonatal Med. 2002 Mar; 11(3): 199-203.
14. Baschat AA, Gembruch U, Viscardi RM, Gortner L, Harman CR. Antenatal prediction of intraventricular hemorrhage in fetal growth restriction: what is the role of Doppler?. Ultrasound Obstet Gynecol. 2002 Apr; 19(4): 334-9.
15. Severi FM, Boochi C, Visentin A, Falco P, Cobellis L, Florio P et al. Uterine and fetal cerebral Doppler predict the outcome of third-trimester small- for- gestational age fetuses with normal umbilical artery Doppler. Ultrasound Obstet Gynecol . 2002 Mar; 19(3): 225-8.
16. Johnson P, Stojilkovic T, Sarkar P. Middle cerebral artery Doppler in severe intrauterine growth restriction. Ultrasound Obstet Gynecol. 2001 May; 17(5): 416-20.
17.Schwarze A, Nelles I, Krapp M, Friedrich M, Schmidt W, Diedrich K et al. Doppler ultrasound of the uterine artery in the prediction of severe complications during low-risk pregnancies. Ultrasound Obstet Gynecol. 2001 May; 17(5): 416-20.
18. Makhseed M, Jirous J, Ahmed MA, Vishwanathan DL. Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. Int J Gynaecol Obset. 2000 Nov; 71(2):119-25.
19. Teixeira JM, Duncan K, Letsky E, Fisk NM. Middle cerebral artery peak systolic velocity in the prediction of fetal anemia. Ultrasound Obstet Gynecol. 2000 Mar; 15(3):205-8.
20. M.Makhseed, J.Jirous, M.A.Ahmed and D.L.Viswanathan. Middle cerebral artery to umbilical artery resistance index ratio in the prediction of neonatal outcome. International Journal of Gynecology & Obstetrics, Volume 71, Issue 2, November 2000, Pages 119-125.
21. Pere-Joan Torres; Eduard Gratacos ; Pedro L. Alonso. Umbilical artery Doppler ultrasound predicts low birth weight anf fetal death in hypertensive pregnancies. Acta Obstetricia et Gynecologica Scandinavica, Volume 74, Issue 5, May 1995, pages 352-355.
Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
Yes, routine blood and urine investigations done during pregnancy (Haemoglobin, blood group, HIV, Hbs Ag, VDRL, blood sugars, urine routine analysis) and transabdominal ultrasound for Doppler studies.
Has ethical clearance been obtained from your institution ?
Yes .
11 / SIGNATURE OF THE
CANDIDATE:
12 / REMARKS OF THE GUIDE :
13 / NAME AND DESIGNATION OF THE GUIDE: / DR. KARKAL PULKERI RABINDRA PRABU
PROF & HOD DEPARTMENT OF RADIODIAGNOSIS & IMAGING
K.S.HEGDE MEDICAL ACADEMY
MANGALORE
14 / SIGNATURE OF THE GUIDE:
15 / CO-GUIDE: / DR. HARISH SHETTY. N
PROF & HOD OF
DEPARTMENT OF OBG
K.S.HEGDE MEDICAL ACADEMY
MANGALORE
16 / SIGNATURE OF CO-GUIDE:
17 / HEAD OF THE DEPARTMENT: / DR. KARKAL PULKERI RABINDRA PRABU
PROF & HOD DEPARTMENT OF RADIODIAGNOSIS & IMAGING
K.S.HEGDE MEDICAL ACADEMY
MANGALORE
18 / SIGNATURE OF THE HEAD OF THE DEPARTMENT:
19 / REMARKS OF CHAIRMAN AND PRINCIPAL:
SIGNATURE:
PROFORMA