Umbilical artery doppler flow patterns in high-risk pregnancy and foetal outcome in Mulago hospital

P. Komuhangi, R. K. Byanyima, E. Kiguli-Malwadde, C. Nakisige

African Centre for Global Health and Social Transformation (ACHEST), Kampala, Uganda.
Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda.
ECUREI, Mengo Hospital, Kampala, Uganda;.
Radiology Department, Mulago Hospital, Kampala, Uganda.

DOI: 10.4236/crcm.2013.29141                

Abstract

Objective: To demonstrate the flow patterns and factors associated with adverse foetal outcome in high-risk pregnancy at Mulago Hospital using Doppler ultrasound of the foetal umbilical artery. Design: Cross-sectional descriptive study. Setting: Mulago National Referral Hospital, Kampala Uganda. Study Subjects: One hundred and ninety-two patients in a 4-month period (December 2008-April 2009). Results: Maternal age was 16 to 41 years. Twenty-one foetuses had abnormal flow patterns (12 had reduced end-diastolic flow, 8 had AEDF and 1 had RF). Prematurity was associated with abnormal flow patterns. 11 out of 12 foetuses with reduced end-diastolic flow survived. Of the foetuses with AEDF, 3 survived but were admitted to the neonatal special care unit while 5 died. One foetus had RF and was a stillbirth. Eighteen foetuses were delivered after an obstetric intervention. Conclusions: 1) The prevalence of abnormal flow patterns is 10.9%. 2) Abnormal flow patterns, low biophysical profile score, premature delivery, low birth weight and low Apgar score are related to adverse foetal outcome. 3) A low biophysical profile score is related to AEDF/RF. 4) Foetuses of low parity mothers are more likely to have abnormal flow patterns. Recommendation: Umbilical artery Doppler Biophysical profile scores should be done in high-risk pregnancy.

 

 

Keywords

Doppler; Umbilical Artery

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Merz, E. (2005) Ultrasound in obstetrics and gynaecology. 2nd Edition, Mainz, Georg Thieme, New York, 507-513.
[2]	Reed, K.L. (1990) Ultrasound in obstetrics. In: Scot, J.R., Disaia, P.J., Hammond, C.B. and Spellacy, Eds., Danforth’s Obstetrics and Gynecology, 6th edition, J.B Lippincott Company, 293.
[3]	Ministry of Health and Uganda National Drug Authority (2003) Uganda clinical guidelines. Ministry of Health and Uganda National Drug Authority, Kampala, 278.
[4]	Cunningham, F.G., Leveno, K.J., John, S.B., Hauth, C., Gilstrap, III and Wenstrom, K.D. and Williams (2005) Obstetrics. 22nd edition, McGraw-Hill Companies, New York, 373-387.
[5]	Bekedam, D.J., Visser, G.H.A., van der Zee, Snijders R.J.M. and Poelmann-Wesjes, G. (1990) Abnormal velocity waveforms of the umbilical arteries in growth-retarded fetuses: Relationship to antepartum late heart rate decelerations and outcome. Early Human Development, 24, 79-89. http://dx.doi.org/10.1016/0378-3782(90)90008-7
[6]	Neilson, J.P. and Alfrevic, Z. (1996) Doppler ultrasound for fetal assessment in high-risk pregnancies. Cochrane Database of Systematic Reviews, 4, Article ID:CD00073. http://dx.doi.org/10.1002/14651858
[7]	World Health Organization (2006) Neonatal and perinatal mortality (country, regional and global estimates). World Health Organization.
[8]	Ministry of Health Uganda (2004) Health sector strategic plan 200/01-2004-05. Ministry of Health Uganda, Kampala, 26.
[9]	Neonatal Special Care Unit of Mulago Hospital (2007) Mulago Hospital Neonatal Special Care Unit records. Mulago Hospital, Kampala.
[10]	Chireu, M., Hartmann, K.E., Berkman, N., et al. (2002) Academic Health Services Policy Meet, 19, 4.
[11]	Velez, D.R., Fortunato, S.J., Morgan, N., et al. (2008) Patterns of cytokine profile differ with pregnancy outcome and ethnicity. Human Reproduction, 23, 1902-1909. http://dx.doi.org/10.1093/humrep/den170
[12]	Nguku, S.W., Wanyoike-Gichuhi, J. and Aywak, A.A. (2006) Biophysical profile scores and resistance indices of the umbilical artery as seen in patients with pregnancy-induced hypertension. East African Medical Journal, 83, 96.
[13]	Neonatal Special Care Unit of Mulago Hospital (2008) Mulago Hospital Neonatal Special Care Unit records. Mulago Hospital, Kampala.
[14]	FitzGerald, D.E. and Drumm, J.E. (1977) Non-invasive measurement of human circulation using ultrasound: A new method. BMJ, 2, 1450. http://dx.doi.org/10.1136/bmj.2.6100.1450
[15]	Campbell, et al. (1983) Uteroplacental circulation: Dupplex scanner. Lancet.
[16]	Mcgrath-Ling, M. (1997) Fetal well-being and fetal death. In: Sanders, R.C. and Miner, N.S., Eds., Clinical Sonography, Lippincott Williams & Wilkins, Baltimore, 173-182.
[17]	Biljan, M., Haddad, N., McVey, K., et al. (1992) Efficiency of continuous wave Doppler in screening high risk pregnancies in a district general hospital (a prospective randomized study of 674 singleton pregnancies). Proceedings of 26th British Congress of Obstetrics and Gynaecology, Manchester, 19 August 1992.
[18]	Burke, G., Stuart, B., Crowley, P., et al. (1992) Does Doppler ultrasound alter the management of high risk pregnancy? Care, concern and cure in perinatal medicine. Parthenon, Carnforth, Amsterdam, 12-15 March 2013.
[19]	Johnstone, F.D., Prescott, R., Hoskins, P., et al. (1993) The effect of introduction of umbilical Doppler recordings to obstetric practice. British Journal of Obstetrics and Gynaecology, 100, 733. http://dx.doi.org/10.1111/j.1471-0528.1993.tb14264.x
[20]	Tyrell, S.N., Lilford, J., MacDonald, H.N., et al. (1990) Randomised comparison of routine vs. highly selective use of Doppler ultrasound and biophysical scoring to investigate high risk pregnancies. British Journal of Obstetrics and Gynaecology, 97, 909-916. http://dx.doi.org/10.1111/j.1471-0528.1990.tb02446.x
[21]	Neales, K., Motteram, J. and Maxwell, D. (1994) A randomised controlled trial to assess the use of Doppler ultrasound in the management of patients with intrauterine growth retardation. Personal Communication, 24 January 1994.
[22]	Nienhuis, S.J. (1995) Costs and effects of Doppler ultrasound measurements in suspected intrauterine growth retardation. A randomised clinical trial. MD Thesis, Universitaire pers Maastrich, Maastricht.
[23]	. Hofmeyr, G.J., Pattinson, R., Buckley, D., et al. (1991) Umbilical artery resistance index as a screening test for fetal wellbeing I, Randomised feasibility study. Obstetrics and Gynaecology, 76, 359.
[24]	Newnham, J.P., O’Dea, M.R., Reid, K.P., et al. (1991) Doppler flow velocity waveform analysis in high risk pregnancies: A randomised controlled trial. British Journal of Obstetrics and Gynaecology, 98, 956-963. http://dx.doi.org/10.1111/j.1471-0528.1991.tb15332.x
[25]	Almstrom, H., Axelson, O., Cnattingius, S., et al. (1992) Comparison of umbilical artery velocimetry and cardiotocography for surveillance of small-for-gestational age fetuses. A multicentre randomised controlled trial. Lancet, 340, 936.
[26]	Trudinger, B.J., Cook, C.M., Giles, W.B., et al. (1987) Umbilical artery flow velocity waveforms in high-risk pregnancy: Randomised controlled trial. Lancet, 1, 188190. http://dx.doi.org/10.1016/S0140-6736(87)90003-1
[27]	Pattinson, L., Norman, K. and Odendaal, H.J. (1992) The role of Doppler velocimetry in the management of pregnancies: A randomised controlled trial. Proceedings of 11th Conference on Priorities in Perinatal Care in South Africa, 59.
[28]	Murray, C. and Lopez, A. (1998) Health dimensions of sex and reproduction. Vol. 3, Global burden of disease and injury series. Harvard University Press, Boston, 219.
[29]	Jimmenez, M.J., Bueno Cavanillas, A., Luna Des Castillo, J.D., et al. (2000) Predictive value of screen for GDM, influence of associated risk factors. Acta Obstetricia et Gynecologica Scandinavica, 79, 991.
[30]	Giles, W.B., Trudinger, B.J. and Blaird, P. (1985) Fetal umbilical artery flow velocity waveforms and placental resistance: Pathologic correlation. BJOG, 92, 31-38. http://dx.doi.org/10.1111/j.1471-0528.1985.tb01045.x
[31]	Macara, L., Kingdom, J.C. and Kaufmann, P. (1996) Structural analysis of placental terminal villi from growth-restricted pregnancies with abnormal umbilical artery Doppler waveforms. Placenta, 17, 37. http://dx.doi.org/10.1016/S0143-4004(05)80642-3
[32]	de Onism, M., Blosner and Villar, J. (1998) Levels and patterns of intrauterine growth retardation in developing countries. European Journal of Clinical Nutrition, 52, 55.
[33]	UNICEF (1998) The state of the world’s children 1998. Oxford University Press, New York.
[34]	Tamura, R.K., Sabaggha, R.E., Depp, R., et al. (1986) Diabetic macrosomia. Accuracy of third trimester ultrasound. Obstetrics & Gynecology, 67, 826-832.
[35]	Campbell, S. (1974) The assessment of foetal development by diagnostic ultrasound. In: Milunsky, A., Ed., Clinics in Perinatology, Saunders, Philadelphia, 507.
[36]	Crane, J.P. and Kopta, M.M. (1979) Prediction of intrauterine growth retardation via ultrasonographic measurement of head/abdominal circumference ratios. obstetrics & Gynecology, 54, 597-601.
[37]	Campbell, S. and Thoms, A. (1977) Ultrasound measurement of the foetal head to abdomen circumference ratio in the assessment of growth retardation. British Journal of Obstetrics & Gynecology, 84,165-174. http://dx.doi.org/10.1111/j.1471-0528.1977.tb12550.x
[38]	Little, D. and Campbell, S. (1982) Ultrasonic evaluation of intrauterine growth retardation. Radiologic Clinics of North America, 20, 335.
[39]	Queenan, J.T., Kabarych, S.F., Cook, L.B., et al., (1976) Diagnostic ultrasound for detection of intrauterine growth retardation. American Journal of Obstetrics and Gynecology, 124, 865.
[40]	Whetham, J.C., Muggah, H. and Davidson, S. (1976) Assessment of intrauterine growth retardation by diagnostic ultrasound. American Journal of Obstetrics and Gynecology, 125, 577-580.
[41]	Chang, T.C., Robson, S.C., Boys, R.J. and Spencer, J.A. (1992) Prediction of the small for age infant: which ultrasonic measurement is best? Obstetrics & Gynaecology, 80, 1030-1038.
[42]	Kish and Leslie (1965) Survey sampling. John Wiley and Sons, New York.
[43]	McGrath Ling, M. (1991) Fetal death and sickness, In: Sanders, R.C., Ed., Clinical Sonography, A Practical Guide, 2nd Edition, Little, Brown and Company, Boston, 163-168.
[44]	Maggio, M. and Sanders, R. (1991) Doppler Principles, In: Sanders, R., Ed., Clinical Sonography, A Practical Guide, 2nd Edition, Little, Brown and Company, Boston, 25-31.
[45]	Hauth, J.C., Ewell, M.G., Levine, R.J., Esterlitz, J.R., Sibai, B., Curet, L.B., Catalano, P.M. and Morris, C.D. (2000) Pregnancy outcomes in healthy nulliparas who developed hypertension. Obstetrics and Gynecology, 95, 24-28. http://dx.doi.org/10.1016/S0029-7844(99)00462-7
[46]	Vatten, L.J. and Skajaerven, R. (2004) Is pre-eclampsia more than one disease? British Journal of Obstetrics & Gynecology, 111, 298-302. http://dx.doi.org/10.1111/j.1471-0528.2004.00071.x
[47]	UNICEF Uganda Statistics (2007)
[48]	World Health Organization (1985) Appropriate Technology for birth. Lancet, 2, 436-437.
[49]	Spinillo, A., Montanari, L., Bergante, C., Gaia, G., Chiara, A. and Fazzi, E. (2005) Prognostic value of Umbilical Artery Doppler studies in unselected preterm deliveries. Obstetrics and Gynecology, 105, 613-620. http://dx.doi.org/10.1097/01.AOG.0000152382.13490.18
[50]	Boschert, S. (2000) Umbilical Doppler studies predict fetal outcome. OB GYN News, 15 June 2000.
[51]	Devendra, A., Desai Sadhana, K., Sheth Prem, N. and Prema, K. (2005) Significance of Umbilical Artery Velocimetry in perinatal outcome of growth restricted fetuses. Journal of Obstetrics & Gynecology of India, 55, 138-143.
[52]	Johnston, F.D., Prescott, R., Hoskins, P., Greer, I.A., McGlew, T. and Compton, M. (1993) The effect of introduction of umbilical Doppler recordings to obstetric practice. British Journal of Obstetrics & Gynecology, 100, 733-741.
[53]	Seyam, Y.S., Al-Mahmeid, M.S. and Al-Tamimi, H.K. Intrauterine growth restriction and its relation to perinatal outcome.
[54]	Byun, Y.J., Kim, H., Yang, J., Kim, J.H., Kim, H.Y. and Chang, S.J. (2009) Umbilical Artery Doppler study as a predictive marker of perinatal outcome in preterm small for gestational age infants. Yongei Medical Journal, 50, 39-44. http://dx.doi.org/10.3349/ymj.2009.50.1.39
[55]	Jouppila, P. Kirkinen, P. (1984) Increased vascular resistance in the descending aorta of the human foetus in hypoxia. British Journal of Obstetrics & Gynecology, 91, 853-856. http://dx.doi.org/10.1111/j.1471-0528.1984.tb03696.x
[56]	Franko, K., Gluckman, P., Law, C., Beedle, A. and Morton, S. (2009) Low birth weight and optimal foetal development, In: Kiess, W. Chermausek, S.D. and Hokken-Koelega A.C.S., Eds., Small for Gestational Age, Causes and Consequences, Archives of Pediatrics and Adolescent Medicine, Basel, Karger.
[57]	American College of Obstetricians and Gynecologists (1999) Antepartum Fetal Surveillance Practice Bulletin. Washington DC.