Clinical Article National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 48-51

Clinical Utility of Colour Doppler for Diagnosis of Adverse

Perinatal Outcome in IUGR and PIH
Swati GoyalA, Shimanku MaheshwariB
ASenior Resident, Department of Radio-diagnosis, All India Institute of Medical
Sciences, Bhopal, M.P., India
BJunior Resident, Department of Obstetrics and Gynecology, Govt. Medical
College, Patiala, Punjab, India
Abstract:

Manuscript Reference
Number: Njmdr_249_14

Objectives: The aim of our study was to evaluate the role of Doppler indices of various
fetal vessels in prediction of perinatal outcome in intrauterine growth retardation
and hypertension; to provide vital information regarding the fetal well being and to
improve neonatal outcome.
Materials & methods: The study population consisted of 60 singleton pregnancy of
> 28 weeks gestation determined by fetal biometry. The pregnancies complicated by
IUGR and hypertension were included.
Results: In our 60 study cases, abnormal S/D ratio was seen in 36(60%) cases; 21(35%)
cases had abnormal umbilical artery PI. Abnormal MCA PI was noted in 23 cases
while abnormal uterine artery S/D ratio was seen in 12 cases. Early diastolic notch
was seen in 20 patients.
Conclusion: Out of the various parameters studied during obstetric sonography the
umbilical artery had maximum sensitivity (65.2%) in predicting adverse perinatal
outcome. Maximum specificity was observed or MCA PI, CU PI ratio and uterine
artery S/D ratio, uterine notch; all of which showed specificity of 92.8%.
Keywords: IUGR, PIH, CDUS (Color Doppler Ultra Sound), Umbilical artery S/D ratio,
MCA PI, Cerebro-umbilical artery PI ratio, Uterine artery S/D ratio, Uterine notch.

Introduction :

Date of submission: 10 August 2014

Date of Editorial approval: 14 August 2014
Date of Peer review approval: 22 August 2014
Date of Publication: 30 September 2014
Conflict of Interest: Nil; Source of support: Nil
Name and addresses of corresponding author:
Dr Swati Goyal,
Senior Resident,
Department of Radio-diagnosis,
All India Institute of Medical Sciences,
Bhopal, M. P., India

complications arising from IUGR and PIH.

Colour Doppler ultrasound has the

potential to transform the face of obstetric
sonography by facilitating prediction as
well as close monitoring of complex fetal
abnormalities especially IUGR (Intra
Uterine Growth Retardation) and PIH
(Pregnancy Induced Hypertension), which
are amongst the most frequent causes of
fetal and perinatal mortality as well as
morbidity in developing countries like
India.

Mobile: 09424427774
Email: swati_97in@yahoo.com

CDUS has ability to focus and detect both

early and late vessel pathologies thus can
help in prediction and management of

48

Materials and Methods:

The study was conducted for one year
in Bhopal medical centre, Bhopal. The
study population consisted of 60 singleton
pregnancies with duly taken informed
consent. Only the pregnancies with
gestational age >28 weeks and complicated
with IUGR & PIH were included.
Pregnancies with congenital abnormalities,
multiple & gestational age < 28 weeks were
excluded. Study of various vessels was
done using Doppler ultrasound (Siemens)
with 3.5 M Hz curvilinear probe with high

National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 48-51

pass filter.

DIAGNOSTIC INDEX OF MIDDLE CEREBRAL ARTERY

PARAMETERS (Table 2)
AS PREDICTOR OF ADVERSE PERINTAL OUTCOME (N=60)

The following vessels were studied with mother in

recumbent position-

PARAMETERS

1) Right and left uterine arteries were identified at the

apparent crossover with external iliac ar-tery

MCA S/D
RATIO

2) Umbilical artery waveform was obtained from the free

loop of umbilical cord midway between placental and
abdominal wall insertion.

MCA A P.I.

3) MCA was located in a transverse plane at the level

of lesser wing of sphenoid bone with a sample gate
placed on the proximal portion of the vessel.
The flow velocity waveforms, PSV, EDV, RI, PI, S/D ratio
of uterine, umbilical artery, MCA were obtained.

Results:

ADVERSE
PERINATAL
OUTCOME
(N=46)

MCA A R.I.

ABNORMAL
(N=26)

24 (True Positive)

2 (False
Positive)

NORMAL
(N=34)

22 ( False Negative)

12 (True
Negative)

ABNORMAL
(N=23)

22 (True Positive)

1 (False
Positive)

NORMAL
(N=37)

24 ( False Negative)

13 (True
Negative)

ABNORMAL
(N=32)

28 (True Positive)

4 (False
Positive)

NORMAL
(N=28)

18 ( False Negative)

10 (True
Negative)

In our study, adverse perinatal outcome was seen in 23 out

of 25 cases with abnormal cerebro umbilical S/D ratio.
(Table 3)
DIAGNOSTIC INDEX OF CEREBRO UMBILICAL RATIOS
(Table 3)

In our 60 study cases, CDUS of umbilical artery, 24 (40%)

had normal S/D ratio and 36(60%) had abnormal S/D ratio.
Out of 36 cases with abnormal S/D ratio, 30 had poor
perinatal outcome while 6 had good outcome. 39 (65%)
cases had normal umbilical artery PI (i.e. <1.4) while 21
(35%) cases had abnormal umbilical artery PI. Out of 21
cases with abnormal umbilical artery PI, 19 had a poor
perinatal outcome and 2 had a good outcome. (Table 1)

AS PREDICTOR OF ADVERSE PERINTAL OUTCOME (N=60)

ADVERSE
GOOD
PERINATAL
PERINTAL
PARAMETERS
OUTCOME
OUTCOME
(N=46)
(N=14)
CU S/D RATIO

CU A P.I.RATIO

DIAGNOSTIC INDEX OF UMBILICAL ARTERY

PARAMETERS (Table 1)
AS PREDICTOR OF ADVERSE PERINTAL OUTCOME (N=60)
ADVERSE
PERINATAL
OUTCOME
(N=46)

PARAMETERS

UMB A S/D
RATIO

UMB A P.I.

UMB A R.I.

ABNORMAL
(N=36)
NORMAL
(N=24)
ABNORMAL
(N=21)
NORMAL
(N=39)
ABNORMAL
(N=24)
NORMAL
(N=36)

30 (True Positive)
16 (False
Negative)
19 (True Positive)
27 (False
Negative)
21 (True Positive)
25 (False
Negative)

GOOD
PERINTAL
OUTCOME
(N=14)

GOOD
PERINTAL
OUTCOME
(N=14)

CU A R.I. RATIO

ABNORMAL
(N=25)

23 (True Positive)

2 (False
Positive)

NORMAL
(N=35)

23 ( False
Negative)

12 (True
Negative)

ABNORMAL
(N=18)

17 (True Positive)

1 (False
Positive)

NORMAL
(N=42)

29 ( False
Negative)

13 (True
Negative)

ABNORMAL
(N=30)

28 (True Positive)

2 (False
Positive)

NORMAL
(N=30)

18 ( False
Negative)

12 (True
Negative)

In our study of 60 cases, 12 had abnormal uterine artery

S/D ratio, out of which 11 had a poor perinatal outcome
and 1 had a good outcome. Difference of >1 between S/D
ratios of two uterine arteries was found in 8 patients. Out
of these 7 had adverse perinatal outcome and 1 had good
perinatal outcome.

6 (False
Positive)
8 (True
Negative)
2 (False
Positive)
12 (True
Negative)
3 (False
Positive)
11 (True
Negative)

Early diastolic notch was observed in 20 patients. Out of

these 19 had a poor perinatal outcome, while 1 had a good
perinatal outcome. (Table 4)

23 cases had abnormal MCA PI, out of which 22 had poor

perinatal outcome and 1 had a good outcome. (Table 2)

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 48-51

DIAGNOSTIC INDEX OF UTERINE ARTERY PARAMETERS

(Table 4)

[2]. Malhotra N concluded that in comparison to AEDV,

REDV had more morbidity. REDV is an indication for
termination of pregnancy [3].

AS PREDICTOR OF ADVERSE PERINTAL OUTCOME (N=60)

ABNORMAL
(N=12)

ADVERSE
PERINATAL
OUTCOME
(N=46)
11 (True
Positive)

GOOD
PERINTAL
OUTCOME
(N=14)
1 (False
Positive)

NORMAL
(N=18)
ABNORMAL
(N=15)
NORMAL
(N=45)
ABNORMAL
(N=15)
NORMAL
(N=45)
PRESENT
(N=20)
ABSENT
(N=40)
ABNORMAL
(N=8)
NORMAL
(N=52)

35 (False
Negative)
14 (True
Positive)
32 (False
Negative)
13 (True
Positive)
33 (False
Negative)
19 (True
Positive)
27 (False
Negative)
7 (True
Positive)
39 (False
Negative)

13 (True
Negative)
1 (False
Positive)
13 (True
Negative)
2 (False
Positive)
12 (True
Negative)
1 (False
Positive)
13 (True
Negative)
1 (False
Positive)
13 (True
Negative)

PARAMETERS

UTA S/D RATIO

UTA A P.I.

UTA A R.I.

UTERINE
NOTCH
UTA S/D DIFF
(difference
b/w
both S/I ratio)

The typical MCA waveform at 28-32 weeks shows high

systolic velocity and minimal diastolic velocity with PI >
1.45. Mild hypoxia, dilates the MCA due to reduced vascular
tone, explaining the brain sparing effect in asymmetric
growth retardation. Fong KW et al concluded that MCA PI
had maximum specificity and NPV while umbilical artery
PI had highest PPV for prediction of adverse perinatal
outcome in IUGR foetuses [4]. Vyas K showed quadratic
relation between fetal hypoxia and degree of reduced PI
of fetal MCA [5]. During the later part of 1st trimester, the
trophoblastic cells invade the spiral artery and convert these
high resistance vessels to passively dilated low resistance
vessels i.e. from low end diastolic flow with early systolic
notch to high diastolic flow and no diastolic notch by 18
- 22 weeks. The upper limit of S/D ratio is approximately
2.6 and differed between two vessels should not exceed 1.

Discussion:
The term IUGR indicates foetuses with weight below the
10th percentile for their gestational ages. The term should
be applied to foetuses affected by a pathological restriction
in their ability to grow.
Type 1- symmetrically small foetuses with normal HC/
AC ratio
Type 2- foetuses with AC< HC /FL
Type 3- foetuses that are symmetric initially but become
asymmetric later in pregnancy
Umbilical artery is one of the easiest vessels to visualize.
Normally as gestation & trophoblastic invasion progresses,
there is a progressive increase in diastolic flow, reflecting
the decrease in placental resistance. Progressive growth
of placental tree increases both systolic and diastolic velocities and reduces PI from 2.0 in early second trimester
to around 1.0 near term. Abnormal waveforms include
decreased end diastolic velocity (EDV), absent EDV and
reversal EDV which represents the high vascular resistance
s/o IUGR. Pattinson et al showed that absent EDV implies
impending fetal distress and is a/w high perinatal mortality
and morbidity [1]. According to Lakhar BN et al, umbilical
artery S/D ratio is the most sensitive (66.6%) index in
predicting any perinatal outcome. MCA PI is the most
specific (90.9%) index in predicting any perinatal out-come

The study by Singh ROB showed a statistically significant

increase in perinatal morbidity and mortality in cases with
abnormal cerebro placental ratio. It was concluded that
doppler identification of fetal brain sparing effect strongly
predicts outcome in such foetuses [6]. Study by Yalti S et al
showed that foetuses with abnormal Doppler velocimetry
had significantly higher incidence of oligohydramnios,
LBW and admission to NICU [7]. Rate of cesarean section
delivery was higher with increase in perinatal morbidity.
Park YW et al concluded that abnormal findings such as
high S/D ratio regardless of placental location and presence
of early diastolic notch in bilateral uterine artery Doppler
velocimetry during second trimester especially warrants
close follow up for detection of subsequent development of
pregnancy complications [8].
Bowler S. Study concluded that early diastolic notch in
uterine artery is better predictor of pre eclampsia at both 20
& 24 weeks [9]. According to Bhatt CJ, S/D >3 in umbilical
artery and >2.6 in uterine artery was considered abnormal
[10]. Arias F. Concluded that ratio of <1.0 identifies a
subgroup of patients at high risk for fetal growth retardation
and severe neonatal morbidity. Our study showed that
umbilical artery S/D ratio had the highest sensitivity
(65.2%) and NPV (33.3%) while umbilical artery PI had
maximum specificity (85.7%) [11].
In comparison, Lakhar et al showed sensitivity of 66.6% and

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National Journal of Medical and Dental Research, July-September 2014: Volume-2, Issue-4, Page 48-51

NPV of 41.6% for umbilical artery S/D ratio and maximum

specificity of 86.6% for umbilical artery PI while Fong et al
MCA PI had highest specificity (92.8%) & PPV (95.6%).
Lakhar et al showed specificity (90.9%) & PPV (88.2%).
Uterine artery S/D ratio and early diastolic notch, each
had specificity of 92.8% in our study. In comparison,
with Lakhar et al specificity for uterine artery S/D ratio
was 90.3% and that of the notch was 95%. The cerebro
umbilical PI ratio had specificity of 92.8% in our study
whereas it is 80.6% in a study conducted by Fong et al.

4. Fong KW, Ohlsson A, Hannah ME, Grisaru S,

Kingdom J, Cohen H, Ryan M, Windrim R, Foster
G, Amankwah K. Prediction of perinatal outcome
in foetuses suspected to have intra ute-rine growth
restriction: Doppler US study of fetal cerebral, renal
and umbilical arteries. Radiology 1999; 213:681-689.
5. Vyas K,Nikolaides KH, Bower S, Campbell S. Middle
cerebral flow velocity waveforms in fetal hypoxemia.
Br J Obstetric Gynaecol Sept 1990;97:707-803.
6. Singh ROB, Kovanci E, Oz U, Deren O, Copel J, Mari
G. The doppler cerebro placental ratio and perinatal
outcome in intrauterine growth restriction. Am J
Obstetric Gynecology 1999;180: 750-6.

Conclusion:
Out of the various parameters studied during obstetric
sonography, the umbilical artery S/D ratio had maximum
sensitivity (65.2%) in predicting adverse perinatal outcome.
Maximum specificity was observed for MCA PI, cerebro
umbilical PI ratio, uterine artery S/D ratio and uterine
notch, all of which showed specificity of 92.8%. Multi
Vessel Colour doppler examination play a vital role in fetal
surveillance and management of pregnancy complicated by
IUGR and /or hypertension, thus can help in improving the
prognosis and perinatal outcome in such pregnancies.
Hence the importance of timely doppler insonation and
waveform analysis in cases of hyperten-sion and suspected
IUGR cannot be over emphasized.

References:
1. Pattinson RC, Norman K,Odendaal HJ. The role of
Doppler velocimetry in the management of high risk
pregnancies. Br J Obstetric Gynaecol 1994;101:114120.
2. Lakhar BN, Rajagopal KV, Gourishankar PT. Doppler
prediction of adverse perinatal outcome in PIH and
IUGR. Ind J Radiol Imag 2006;16 (1):109-116.

7. Yalti S, Oral O, Gurbuz B,Ozden S, Atar F. Ratio of

middle cerebral to umbilical artery blood velocity in
preeclamptic and hypertensive women in prediction of
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9. Bower S, Bewley S, Campbell S. Improved prediction
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in pregnancy induced hypertension. (A study of 100
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11. Arias F. Accuracy of the middle cerebral to umbilical
artery resistance index ratio in the pre-diction of
neonatal outcome in patients at high risk for fetal
and neonatal complications. Am J obstetric Gynecol
1994;171: 1541-5.

3. Malhotra N, Chanana C, Kumar S, Roy K,Sharma JB.

Comparison of perinatal outcome of growth restricted
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