EARLY
DETECTION
AND
DETERMINATION
THE
DOPPLER
M.
M.
OF
HEART OF
ULTRASONIC
Tembotova
ACTION
PLACENTA
IN
THE
POSITION
FETUS WITH
METHOD
UDC 618.2-073.432.19
One of the m o s t important p r o b l e m s of m o d e r n o b s t e t r i c s is the prenatal c a r e of the fetus; in a c c o m plishing this a determination of the intrauterine status is of g r e a t value. The principal indication of the condition of a fetus is its h e a r t action. A determination of a heartbeat at an e a r l y stage of a pregnancy is an important diagnostic test, e s p e c i a l l y when there are bloody d i s c h a r g e s f r o m the genital p a s s a g e s of a pregnant woman, a suspicion of an undeveloped p r e g n a n c y , o r a cystic accumulation, and also when making a differential diagnosis between a p r e g n a n c y and a f a s t - g r o w i n g t u m o r of the uterus. Recently e l e c t r o c a r d i o g r a p h y and phonocardiography have become commonplace in o b s t e t r i c a l p r a c tice in examining the h e a r t action of a fetus; these p e r m i t the heartbeat to be detected at the 18th to 20th week of a pregnancy, and in r a r e c a s e s between the 14th and 15th weeks. Along with these the ultrasonic method is employed, thus making it possible to determine heart action in a fetus at an e a r l y stage of pregnancy. C o m p a r e d to the e l e c t r o c a r d i o g r a p h i c method it gives s i m p l e r information - a r e c o r d of the heartbeat. To a n s w e r the question of whether a fetus is alive o r dead under a v a r i e t y of pathologies during e a r l y pregnancies the ultrasonic method is quicker and s i m p l e r . The use of the Doppler effect f o r the examination of a f e t u s ' heart has been described in [1-4]. This method has been employed in our c o u n t r y by V. I. Demidov and A. A. A r i s t o v to detect a fetal heartbeat a t a n e a r l y stage of p r e g n a n c y and to locate the position of the placenta [5]. By m e a n s of clinical and experimental w o r k [6-8] it has been established that the ultrasonic method, when used for diagnostic and therapeutic p u r p o s e s , is h a r m l e s s to both fetus and m o t h e r . * The objective of the p r e s e n t article was to e s t a b l i s h the e a r l i e s t stages at which a fetal heartbeat can be determined, to study the possibilities of ultrasonic apparatus based on the Doppler effect in establishing w h e t h e r a fetus is alive o r dead under a v a r i e t y of pathologies, to make observations at an e a r l y stage of p r e g n a n c y (threat of a m i s c a r r i a g e o r suspected undeveloped pregnancy), to determine the rate of a fetal h e a r t b e a t a t a n e a r l y stage of pregnancy, and also to determine the position of the placenta. The Dopton-205 (with a power of 12 m W / c m 2 at a f r e q u e n c y of 2MI-Iz) and the type FM-2 (with a power of 5 m W / c l n 2 at a f r e q u e n c y of 2MHz) made by the Sonicaid Company (England) w e r e the ultrasonic appar a t u s e s employed. F o r the detection of fetal heart action 272 women who were between 7 and 20 weeks pregnant were examined. It was found that 109 out of 226 women having a n o r m a l p r e g n a n c y w e r e between 7 and 9 weeks • E d i t o r ' s note: In the newspaper "Kiodo Tsusin" for July 11, 1972 it was r e p o r t e d that the Association of Japanese Gynecologists and Obstetricians had published in the journal "Maternity Welfare" a warning about the danger of employing m o d e r n ultrasonic diagnostic instruments during the f i r s t three months of a p r e g nancy, and r e c o m m e n d e d that its use be r e s t r i c t e d in the l a t e r stages. The use of u l t r a s o n i c instruments to detect a fetal h e a r t b e a t gained widespread use in 1964. Dr. Tetsuya (University of Hokkaido) pointed out that the use of t h e s e i n s t r u m e n t s might cause deformity of a fetus. Experiments were p e r f o r m e d on 51 m i c e at an e a r l y stage of pregnancy; t h r e e of t h e s e m i c e bore offspring without a brain. Central Institute f o r Advanced Medical Studies, ~Ioscow. T r a n s l a t e d f r o m Meditsinskaya Tekhnika, No. 2, pp. 42-43, IV[arch-April, 1974. Original article submitted June 18, 1973. © 1974 Consultants Bureau, a division of Plenum Publishing Corporation, 227 West 17th Street, New York, N. Y. 10011. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission of the publisher. A copy of this article is available from the publisher for $15.00.
103
pregnant, and fetal heart action was found in 33 of them. Of 75 women who were between 10 and 12 weeks pregnant the ultrasonic examination gave positive r e s u l t s on 60. Fetal heart action was established in all 42 women who were between 13 and 20 weeks pregnant. According to our data the rate of the fetal heartbeat at an e a r l y stage of pregnancy is usually between 140 and 160 per minute, which is somewhat g r e a t e r than at the end of a pregnancy. We employed the ultrasonic Doppler method to determine whether a fetus was alive o r dead for women who were in an i n f i r m a r y with various pathologies of the e a r l y stage of a pregnancy. The examination was p e r f o r m e d after the 12th week of a pregnancy, i.e., after the organogenesis of the fetus was, for the most part, completed and the ultrasonic method gave r a t h e r a c c u r a t e information r e g a r d i n g the vitality of the fetus. F o r t y - t w o pregnant women were examined f o r a suspected undeveloped pregnancy and a threat of a m i s c a r r i a g e during the 1 3 - t o 20-weekperiod. No heartbeat was found with the ultrasonic method in 5 of those examined. A f t e r 1 to 3 days a spontaneous m i s c a r r i a g e took place. F u r t h e r clinical observation of the remaining 37 pregnant women confirmed the developing pregnancy. The Doppler ultrasonic method was used for a differential diagnosis between a p r e g n a n c y and a f a s t growing t u m o r on 11 women. In 7 of them the heart action of a developing fetus was detected. Repeated examinations of 4 women suggested that there was a f a s t : g r o w i n g uterine t u m o r which was l a t e r confirmed cl inic ally. In o r d e r to localize a placenta by the ultrasonic method 78 women were examined who had been p r e g nant between 30 and 42 weeks. A check was made at the time of a C a e s a r i a n section and by a manual inspection of the cavity walls in the postnatal uterus. When placentas are located on the front wall of the uterus in the l o w e r uterine segment, the c h a r a c t e r i s t i c sounds of a functioning placenta are heard which a r e synchronized with the rhythm of the fetal heartbeat. A diagnosis of a placenta on the r e a r wall of the uterus was established by a p r o c e s s of elimination. An e r r o n e o u s diagnosis was made in 6 c a s e s . In 2 of 5 c a s e s no diagnosis of the placental p r e s e n tation could be made. F o r 3 women the location of the placenta was e r r o n e o u s l y diagnosed as being on the front wall of the uterus (when checked it was on the r e a r wall). In one case a placenta on the front wall was not revealed (the check showed it to be attached to a s c a r on the uterus f r o m a previous upper segment C a e s a r i a n section). Our observations indicated that it is possible to detect fetal heartbeats and to determine the placental position r e g a r d l e s s of the e x a m i n e e ' s age, the n u m b e r of previous p r e g n a n c i e s , and their result. The experience in using the Dopton-205 and the type FM-2 apparatuses has d e m o n s t r a t e d that for the f u r t h e r development of ultrasonic diagnostic apparatus of a s i m i l a r s o r t it is advisable to limit the level of the v e r y s t r o n g signals that o c c u r when the ultrasonic t r a n s d u c e r is applied to the integuments of the examineeTs abdominal wall. These signals are manifested by a s t r o n g crackling as the t r a n s d u c e r is shifted over the integuments. In o r d e r to distinguish the difference between the sound of the placenta and the fetal heartbeat, it would be desirable to develop amplifiers and a s y s t e m of audio filters that would p e r m i t a c l e a r e r distinction to be made between the sounds emitted by the placenta, the umbilical c o r d , and the fetal heartbeat. Making it e a s i e r to recognize the sound of the placenta as we have a s s u m e d will allow the use of ultrasonic t r a n s d u c e r s having different directional c h a r a c t e r i s t i c s . We believe it v e r y desirable to develop an ultrasonic diagnostic apparatus that would make it possible to obtain an e a r l y diagnosis of pregnancy and to follow the status of the fetal heart action in labor; i.e., the functional potentialities of the Dopton-205 and the type F M-2 should be combined in a single apparatus. Since such apparatus m i g h t be used under a v a r i e t y of conditions such as in female consulting, prenatal and m a t e r n i t y w a r d s , as well as other places, it is v e r y important that it should be t r a n s p o r t a b l e and portable. CONCLUSIONS 1. An ultrasonic examination with apparatus based on the Doppler effect will under c e r t a i n conditions make it possible to detect the fetal heartbeat beginning with the 7th to 8th week of pregnancy. When a p r e g n a n c y is over 1 3 w e e k s , t h e life o r death of a fetus is established with certainty.
104
2. The r a t e of a fetal h e a r t b e a t at an e a r l y stage of a p r e g n a n c y is usually between 140 and 160 p e r minute. 3. An u l t r a s o n i c e x a m i n a t i o n m a k e s it possible to d e t e r m i n e w h e t h e r t h e r e is a h e a r t b e a t when a m i s c a r r i a g e is t h r e a t e n e d , and when an undeveloped p r e g n a n c y is s u s p e c t e d , thus enabling a doctor to take the p r o p e r steps. 4. The Doppler u l t r a s o n i c method is r a p i d , s i m p l e , and sufficiently a c c u r a t e to d e t e r m i n e the p o s i tion of the placenta. 5. An u l t r a s o n i c e x a m i n a t i o n takes f r o m 1 to 3 m i n , r e q u i r e s no special p r e p a r a t i o n of the women, evokes no unpleasant s e n s a t i o n s in the e x a m i n e e , and has no effect on the future development of the fetus. LITERATURE 1. 2. 3. 4. 5. 6. 7. 8.
CITED
A. Dwight et al., P r e s s e M6d., 75, 2136 (1965). R . L . B e r n s t i n e and D. A. Callagan, Am. J. Obstet. Gynec., 95, 1001 (1966). H. W e v e r and H. Stockhausen, Geburtsh. u. F r a u e n h e i l k , 27, 1209 (1967). A. Brown and J. R o b e r t s o n , J. Obstet. Gynaee. Brit. Cwlth., 75, 92 (1968). V . N . Demidov and A. A. A r i s t o v , Akush. i Gin., No. 3, 64 (1972). D. K a m o e h a i , Vopr. K u r o r t o l . , No. 2, 131 (1962). M. Bobrov, N. Blaekwell, and A. Unrau, J. Obstet. Gynaec. Brit. Cwlth., 78, 730 (1971). P . K . A b r a m o w s k i , K. W. S t u r m , H. dung, et al, Z. Geburtsh. Gyn~tk, 176,286 (1972).
105
DETECTION
AND
DETERMINATION
THE
DOPPLER
M.
M.
OF
HEART OF
ULTRASONIC
Tembotova
ACTION
PLACENTA
IN
THE
POSITION
FETUS WITH
METHOD
UDC 618.2-073.432.19
One of the m o s t important p r o b l e m s of m o d e r n o b s t e t r i c s is the prenatal c a r e of the fetus; in a c c o m plishing this a determination of the intrauterine status is of g r e a t value. The principal indication of the condition of a fetus is its h e a r t action. A determination of a heartbeat at an e a r l y stage of a pregnancy is an important diagnostic test, e s p e c i a l l y when there are bloody d i s c h a r g e s f r o m the genital p a s s a g e s of a pregnant woman, a suspicion of an undeveloped p r e g n a n c y , o r a cystic accumulation, and also when making a differential diagnosis between a p r e g n a n c y and a f a s t - g r o w i n g t u m o r of the uterus. Recently e l e c t r o c a r d i o g r a p h y and phonocardiography have become commonplace in o b s t e t r i c a l p r a c tice in examining the h e a r t action of a fetus; these p e r m i t the heartbeat to be detected at the 18th to 20th week of a pregnancy, and in r a r e c a s e s between the 14th and 15th weeks. Along with these the ultrasonic method is employed, thus making it possible to determine heart action in a fetus at an e a r l y stage of pregnancy. C o m p a r e d to the e l e c t r o c a r d i o g r a p h i c method it gives s i m p l e r information - a r e c o r d of the heartbeat. To a n s w e r the question of whether a fetus is alive o r dead under a v a r i e t y of pathologies during e a r l y pregnancies the ultrasonic method is quicker and s i m p l e r . The use of the Doppler effect f o r the examination of a f e t u s ' heart has been described in [1-4]. This method has been employed in our c o u n t r y by V. I. Demidov and A. A. A r i s t o v to detect a fetal heartbeat a t a n e a r l y stage of p r e g n a n c y and to locate the position of the placenta [5]. By m e a n s of clinical and experimental w o r k [6-8] it has been established that the ultrasonic method, when used for diagnostic and therapeutic p u r p o s e s , is h a r m l e s s to both fetus and m o t h e r . * The objective of the p r e s e n t article was to e s t a b l i s h the e a r l i e s t stages at which a fetal heartbeat can be determined, to study the possibilities of ultrasonic apparatus based on the Doppler effect in establishing w h e t h e r a fetus is alive o r dead under a v a r i e t y of pathologies, to make observations at an e a r l y stage of p r e g n a n c y (threat of a m i s c a r r i a g e o r suspected undeveloped pregnancy), to determine the rate of a fetal h e a r t b e a t a t a n e a r l y stage of pregnancy, and also to determine the position of the placenta. The Dopton-205 (with a power of 12 m W / c m 2 at a f r e q u e n c y of 2MI-Iz) and the type FM-2 (with a power of 5 m W / c l n 2 at a f r e q u e n c y of 2MHz) made by the Sonicaid Company (England) w e r e the ultrasonic appar a t u s e s employed. F o r the detection of fetal heart action 272 women who were between 7 and 20 weeks pregnant were examined. It was found that 109 out of 226 women having a n o r m a l p r e g n a n c y w e r e between 7 and 9 weeks • E d i t o r ' s note: In the newspaper "Kiodo Tsusin" for July 11, 1972 it was r e p o r t e d that the Association of Japanese Gynecologists and Obstetricians had published in the journal "Maternity Welfare" a warning about the danger of employing m o d e r n ultrasonic diagnostic instruments during the f i r s t three months of a p r e g nancy, and r e c o m m e n d e d that its use be r e s t r i c t e d in the l a t e r stages. The use of u l t r a s o n i c instruments to detect a fetal h e a r t b e a t gained widespread use in 1964. Dr. Tetsuya (University of Hokkaido) pointed out that the use of t h e s e i n s t r u m e n t s might cause deformity of a fetus. Experiments were p e r f o r m e d on 51 m i c e at an e a r l y stage of pregnancy; t h r e e of t h e s e m i c e bore offspring without a brain. Central Institute f o r Advanced Medical Studies, ~Ioscow. T r a n s l a t e d f r o m Meditsinskaya Tekhnika, No. 2, pp. 42-43, IV[arch-April, 1974. Original article submitted June 18, 1973. © 1974 Consultants Bureau, a division of Plenum Publishing Corporation, 227 West 17th Street, New York, N. Y. 10011. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission of the publisher. A copy of this article is available from the publisher for $15.00.
103
pregnant, and fetal heart action was found in 33 of them. Of 75 women who were between 10 and 12 weeks pregnant the ultrasonic examination gave positive r e s u l t s on 60. Fetal heart action was established in all 42 women who were between 13 and 20 weeks pregnant. According to our data the rate of the fetal heartbeat at an e a r l y stage of pregnancy is usually between 140 and 160 per minute, which is somewhat g r e a t e r than at the end of a pregnancy. We employed the ultrasonic Doppler method to determine whether a fetus was alive o r dead for women who were in an i n f i r m a r y with various pathologies of the e a r l y stage of a pregnancy. The examination was p e r f o r m e d after the 12th week of a pregnancy, i.e., after the organogenesis of the fetus was, for the most part, completed and the ultrasonic method gave r a t h e r a c c u r a t e information r e g a r d i n g the vitality of the fetus. F o r t y - t w o pregnant women were examined f o r a suspected undeveloped pregnancy and a threat of a m i s c a r r i a g e during the 1 3 - t o 20-weekperiod. No heartbeat was found with the ultrasonic method in 5 of those examined. A f t e r 1 to 3 days a spontaneous m i s c a r r i a g e took place. F u r t h e r clinical observation of the remaining 37 pregnant women confirmed the developing pregnancy. The Doppler ultrasonic method was used for a differential diagnosis between a p r e g n a n c y and a f a s t growing t u m o r on 11 women. In 7 of them the heart action of a developing fetus was detected. Repeated examinations of 4 women suggested that there was a f a s t : g r o w i n g uterine t u m o r which was l a t e r confirmed cl inic ally. In o r d e r to localize a placenta by the ultrasonic method 78 women were examined who had been p r e g nant between 30 and 42 weeks. A check was made at the time of a C a e s a r i a n section and by a manual inspection of the cavity walls in the postnatal uterus. When placentas are located on the front wall of the uterus in the l o w e r uterine segment, the c h a r a c t e r i s t i c sounds of a functioning placenta are heard which a r e synchronized with the rhythm of the fetal heartbeat. A diagnosis of a placenta on the r e a r wall of the uterus was established by a p r o c e s s of elimination. An e r r o n e o u s diagnosis was made in 6 c a s e s . In 2 of 5 c a s e s no diagnosis of the placental p r e s e n tation could be made. F o r 3 women the location of the placenta was e r r o n e o u s l y diagnosed as being on the front wall of the uterus (when checked it was on the r e a r wall). In one case a placenta on the front wall was not revealed (the check showed it to be attached to a s c a r on the uterus f r o m a previous upper segment C a e s a r i a n section). Our observations indicated that it is possible to detect fetal heartbeats and to determine the placental position r e g a r d l e s s of the e x a m i n e e ' s age, the n u m b e r of previous p r e g n a n c i e s , and their result. The experience in using the Dopton-205 and the type FM-2 apparatuses has d e m o n s t r a t e d that for the f u r t h e r development of ultrasonic diagnostic apparatus of a s i m i l a r s o r t it is advisable to limit the level of the v e r y s t r o n g signals that o c c u r when the ultrasonic t r a n s d u c e r is applied to the integuments of the examineeTs abdominal wall. These signals are manifested by a s t r o n g crackling as the t r a n s d u c e r is shifted over the integuments. In o r d e r to distinguish the difference between the sound of the placenta and the fetal heartbeat, it would be desirable to develop amplifiers and a s y s t e m of audio filters that would p e r m i t a c l e a r e r distinction to be made between the sounds emitted by the placenta, the umbilical c o r d , and the fetal heartbeat. Making it e a s i e r to recognize the sound of the placenta as we have a s s u m e d will allow the use of ultrasonic t r a n s d u c e r s having different directional c h a r a c t e r i s t i c s . We believe it v e r y desirable to develop an ultrasonic diagnostic apparatus that would make it possible to obtain an e a r l y diagnosis of pregnancy and to follow the status of the fetal heart action in labor; i.e., the functional potentialities of the Dopton-205 and the type F M-2 should be combined in a single apparatus. Since such apparatus m i g h t be used under a v a r i e t y of conditions such as in female consulting, prenatal and m a t e r n i t y w a r d s , as well as other places, it is v e r y important that it should be t r a n s p o r t a b l e and portable. CONCLUSIONS 1. An ultrasonic examination with apparatus based on the Doppler effect will under c e r t a i n conditions make it possible to detect the fetal heartbeat beginning with the 7th to 8th week of pregnancy. When a p r e g n a n c y is over 1 3 w e e k s , t h e life o r death of a fetus is established with certainty.
104
2. The r a t e of a fetal h e a r t b e a t at an e a r l y stage of a p r e g n a n c y is usually between 140 and 160 p e r minute. 3. An u l t r a s o n i c e x a m i n a t i o n m a k e s it possible to d e t e r m i n e w h e t h e r t h e r e is a h e a r t b e a t when a m i s c a r r i a g e is t h r e a t e n e d , and when an undeveloped p r e g n a n c y is s u s p e c t e d , thus enabling a doctor to take the p r o p e r steps. 4. The Doppler u l t r a s o n i c method is r a p i d , s i m p l e , and sufficiently a c c u r a t e to d e t e r m i n e the p o s i tion of the placenta. 5. An u l t r a s o n i c e x a m i n a t i o n takes f r o m 1 to 3 m i n , r e q u i r e s no special p r e p a r a t i o n of the women, evokes no unpleasant s e n s a t i o n s in the e x a m i n e e , and has no effect on the future development of the fetus. LITERATURE 1. 2. 3. 4. 5. 6. 7. 8.
CITED
A. Dwight et al., P r e s s e M6d., 75, 2136 (1965). R . L . B e r n s t i n e and D. A. Callagan, Am. J. Obstet. Gynec., 95, 1001 (1966). H. W e v e r and H. Stockhausen, Geburtsh. u. F r a u e n h e i l k , 27, 1209 (1967). A. Brown and J. R o b e r t s o n , J. Obstet. Gynaee. Brit. Cwlth., 75, 92 (1968). V . N . Demidov and A. A. A r i s t o v , Akush. i Gin., No. 3, 64 (1972). D. K a m o e h a i , Vopr. K u r o r t o l . , No. 2, 131 (1962). M. Bobrov, N. Blaekwell, and A. Unrau, J. Obstet. Gynaec. Brit. Cwlth., 78, 730 (1971). P . K . A b r a m o w s k i , K. W. S t u r m , H. dung, et al, Z. Geburtsh. Gyn~tk, 176,286 (1972).
105
