http://informahealthcare.com/jmf ISSN: 1476-7058 (print), 1476-4954 (electronic) J Matern Fetal Neonatal Med, 2014; 27(18): 1880–1885 ! 2014 Informa UK Ltd. DOI: 10.3109/14767058.2014.892068
ORIGINAL ARTICLE
Fetal middle cerebral and umbilical artery Doppler after 40 weeks gestational age
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Ahmed M. Maged, Aly Abdelhafez, Walaa AI Mostafa, and Wael Elsherbiny Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Cairo, Egypt
Abstract
Keywords
Objective: To determine the value of fetal Doppler indices named middle cerebral artery (MCA)-PI, umbilical artery (UA)-PI and MCA-PI/UA-PI ratio, and amniotic fluid volume assessment in pregnancies 280–294 d and their correlation with the mode of delivery and perinatal outcome. Study design: Prospective observational study conducted on 100 whose gestational age (GA) from 40 to 42 weeks. MCA and UA Doppler and MCA-PI/UA-PI ratio, amniotic fluid volume (AFV) were assessed. They were divided into two groups based on the presence or absence of adverse perinatal outcome. Results: Women with adverse perinatal outcome showed lower MCA-PI (0.92 versus 1.29), MCA-PI:UA-PI ratio (1.04 versus 1.83), lower gestational age when assessed by ultrasound (37.82 versus 39.48 weeks), lower neonatal birth weight (2705 versus 3108 g), fetal biophysical profile (BPP) (4.55 versus 7.21) when compared to women with normal perinatal outcome. They also had higher cases with oligohydramnios (34 versus 5), and higher UA-PI (0.89 versus 0.72). Conclusion: Women with adverse neonatal outcome had higher UA-PI and lower MCA-PI, MCA-PI:UA-PI ratio, GA (by US), AFV, BPP, estimated fetal weight, neonatal birth weight when compared to those with normal perinatal outcome. Women with adverse neonatal outcome had a higher rate of cesarean section mostly due to fetal distress and induced VD due to oligohydraminos compared to the normal outcome group.
Amniotic fluid volume, Doppler velocimetry, mode of delivery, perinatal outcome
Introduction The international definition of prolonged pregnancy is 42 completed weeks (294 days) or more from the first day of the last menstrual period [1]. The incidence of postterm pregnancy ranges from 4% to 19% [2]. MacDorman and Kirmeyer reported increased perinatal mortality rate if pregnancy exceeded 41 weeks [3]. The major causes of fetal death include gestational hypertension, prolonged labor with cephalopelvic disproportion, ‘‘unexplained anoxia’’ and malformations [4]. Children born postterm have more developmental abnormalities compared with those born before 42 weeks [5]. The problems of prolonged pregnancy can be decreased by routine antepartum fetal surveillance prior to onset of spontaneous labor [6]. A safe limit for continuation of pregnancy beyond expected date of delivery cannot be established. Some suggested that risk of postmaturity starts at 40 weeks [7]. ACOG suggested that initiation of fetal surveillance at 41 weeks is a reasonable option [1]. Address for correspondence: Ahmed Mohamed Maged, Department of Obstetrics and Gynecology, Kasr Aini Hospital, Cairo University, 135 King Faisal Street Haram Giza, Postal code 12151, Cairo, Egypt. Tel: +01005227404. Fax: 35873103. E-mail: [email protected]
History Received 29 October 2013 Revised 20 January 2014 Accepted 4 February 2014 Published online 27 February 2014
Fetal Doppler velocimetry has been used as a good parameter for assessment of fetal well-being. A large experience with this technique has been reported with respect to the prediction of the fetus at risk of developing IUGR, antepartum and intrapartum fetal asphyxia, and neonatal morbidity [8]. Several studies indicated that Doppler indices may be powerful predictors of adverse perinatal outcome in complicated pregnancies [9]. The aim of this study was to determine the value of fetal Doppler indices named middle cerebral artery (MCA)-PI, umbilical artery (UA)-PI and MCA-PI/UA-PI ratio, and amniotic fluid volume assessment in pregnancies 40–42 weeks’ gestation and their relation with the mode of delivery and perinatal outcome.
Materials and methods This prospective observational study was carried out on 100 women whose gestational age (GA) was 40–42 weeks’ gestation attending the antenatal clinic of Kasr AL-Aini Maternity Hospital from December 2009 to July 2012. The study was approved by local ethics committee, and an informed oral consent was obtained from all participants. Inclusion criteria included singleton living fetuses with vertex presentation. An accurate estimation of GA (from 280 to 294 d) was calculated from the first day of regular last
Doppler in pregnancy 40 weeks plus
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DOI: 10.3109/14767058.2014.892068
menstrual period and confirmed or modified by an early ultrasound examination before 20 weeks gestation. Exclusion criteria included cases with premature rupture of membranes, antepartum hemorrhage, patients in labor and maternal medical disorders as hypertension, diabetes mellitus, hepatic, cardiac, renal or anemia with pregnancy. Patients with a uterine scar or any condition contraindicating induction of labor were also excluded. All patients were subjected to detailed history taking, physical examination and routine investigations including complete blood picture, RH typing, fasting blood sugar, liver functions, kidney functions and urine analysis. Ultrasound and Doppler study was done twice weekly till the onset of labor or termination of pregnancy in order to assess GA, estimated fetal weight (EFW), placental site and grading, amniotic fluid volume (AFV) (oligohydraminos was diagnosed if the largest vertical pocket 2 cm), Doppler study of the MCA and UA and modified fetal biophysical profile (BPP) scoring system. Transabdominal ultrasound was performed while woman was in a slightly tilted position with the head of the bed raised 30 and a small pillow under the right loin. The apparatus used was the Voluson ProV GE ultrasound machine (GE Shareowner Company Fairfield, Piscataway, NJ) with Doppler unit and convex linear transducer 3.5 MHz. GA determination was done by assessment of biparietal diameter, femur length and abdominal circumference. Fetal weight estimation was detected according to Hadlock using the head, abdomen and femur measurements [10]. Fetal-modified BPP scoring: four fetal biophysical variables: fetal breathing movements, gross body movements, fetal tone, qualitative amniotic fluid volume were measured. The duration of observation was extended until each variable met normal criteria or 30 min period has passed. During each observation period, each variable was scored as 2 or 0 score. A score 4 was considered abnormal [11]. UA Doppler was done while the patient placed in a semirecumbent position with a left lateral tilt and the uterine contents are scanned to select an area of amniotic cavity with several loops of umbilical cord. Ideally these cord loops should not be close to the cord insertion [12]. Then, using a pulsed wave Doppler on a free loop of cord, the characteristic sound and shape of the UA was identified. A minimum of three separate readings were averaged before the final values were obtained. Recording was performed during periods of fetal apnea. Cut-off point used in this study for PI was 0.82 [13]. The standard plane for measuring MCA Doppler is the transthalamic plane which contains the thalami and cavum septum pellucidum. The MCA can be seen pulsating at the level of origin of the circle of Willis. Care was taken not to exert pressure on the fetal head because this alters the flow velocity waveforms from the MCA [14]. Cut-off point used in this study for PI was 1.0 [15]. The cerebro-placental ratio (CPR) was calculated. Cut-off point used in this study for CPR is 1.05 [16]. Spontaneous vaginal delivery was awaited, but induction of delivery was commenced if there is oligohydraminos, BPP is 6 or if the period of gestation extended beyond 42 weeks.
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With a Bishop score 47, labor was induced by oxytocin infusion (47%) (starting with 5 IU in 500 ml Ringer solution and the dose rate increased according to the response) and/or artificial amniotomy (15%). Oxytocin (Syntocinon, 5 IU ampoules, Novartis Pharma, Amiria, Cairo, Egypt). Otherwise, cervical ripening was induced with one tablet of transvaginal prostaglandins E1 (Vagiprost, 25 mg tablets, ADWIA Pharmaceuticals, Amiria, Cairo, Egypt). (10%) the patient was reassessed after 6 h and received another dose if required. FHS was auscultated every 15 min using fetal Doppler, and once in the active stage of labor (cervical dilatation 43 cm), amniotomy was performed and liquor was observed for meconium staining. Cardiotocography (CTG) was done for 20 min before the induction of labor. CTG was repeated when needed during the induction. CTG tracing was considered abnormal when there was persistent late decelerations or persistent variable decelerations and diminished FHR variability (55 bpm). These cases were terminated by CS. The study population was divided into two groups based on the presence or absence of adverse perinatal outcome. Adverse perinatal outcome was defined as the presence of one or more of the following: Cesarean delivery for fetal distress, Apgar score 57 at 1 and 5 min, meconium aspiration syndrome (MAS) or neonatal intensive care unit (NICU) admission. MAS was diagnosed with the visual observation of greenish fluid discoloration with respiratory difficulties and an evidence of over-expansion and widespread coarse infiltration of the lungs on chest X-ray [17]. Fetus/neonate was considered to be distress if any one of the following was present: [18] (1) Ominous FHR changes led to caesarean section (LSCS) or forceps/ventouse delivery. (2) Presence of moderate–thick meconium stained liquor (MSL). (3) Apgar score at 5 min 57. (4) Umbilical cord arterial blood pH57.2. (5) Admission into NICU for birth asphyxia. (6) Neonatal seizures within first 24–48 h. (7) Incidence of intrapartum/neonatal mortality. Data were collected, verified and revised. Continuous data were expressed as means ± standard deviation. Categorical data were presented in the form of number and percentage. Comparison between the two groups was performed using student unpaired t test and chi-square test. ROC curve was used to determine the sensitivity and specificity of the different Doppler techniques. The data were considered significant if p values was 0.05, highly significant if p50.01. Statistical analysis was performed with the aid of the SPSS computer program (version 12 windows, SPSS Inc., Chicago, IL).
Results There was no statistically significant difference between the two groups as regards the maternal age, height, weight, gravidity, parity or GA at time of testing (Table 1). The adverse outcome group had lower GA (by US), EFW, neonatal birth weight, BPP, MCA-PI and MCA-PI:UA-PI
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Table 1. Demographic data of the two studied groups.
Parameter Maternal age (years) Maternal height (cm) Maternal weight (kg) GA at delivery (d) Gravidity Parity
Adverse (n ¼ 44) 25.02 ± 4.22 160.25 ± 3.81 79.18 ± 6.09 283.07 ± 39.41 1.07 ± 1.49 0.59 ± 0.97
Normal (n ¼ 56) 25.29 ± 3.64 159.32 ± 3.97 76.98 ± 6.74 281.66 ± 34.79 1.02 ± 1.45 0.59 ± 0.91
Table 4. Comparison between both groups as regards the mode of delivery, indications of CS and indications of induced VD. p value NS
0.739 0.240NS 0.094NS 0.850NS 0.865NS 0.993NS
NS, not significant (p40.05).
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Table 2. Comparison between both groups as regards: GA, BPP, UA-PI, MCA-PI, MCA-PI:UA-PI ratio and EFW.
Parameter GA US (weeks) EFW (g) Neonatal birthweight BBP UA-PI MCA-PI MCA-PI:UA-PI ratio
Parameter CS Induced VD Spontaneous VD Indications of CS Failed induction Failure of progress Fetal distress Indications of induced VD BPP56/8 Oligohydraminos Reaching 42 weeks
Adverse (n ¼ 44)
Normal (n ¼ 56)
31 (70.5%) 10 (22.7%) 3 (6.8%)
25 (44.6%) 11 (19.6%) 20 (35.7%)
0.002**
5 (16.1%) 1 (3.2%) 25 (80.6%)
9 (36.0%) 16 (64.0%) 0 (0%)
0.001**
1 (10%) 9 (90%) 0 (0%)
7 (63.6%) 2 (18.2%) 2 (18.2%)
0.004**
p value
**p50.001, highly significant.
Adverse (n ¼ 44)
Normal (n ¼ 56)
p value
37.82 ± 0.87 2798.41 ± 28 2705.34 ± 29 4.55 ± 1.85 0.89 ± 0.12 0.92 ± 0.18 1.04 ± 0.19
39.48 ± 0.91 3221.25 ± 32 3108.21 ± 31 7.21 ± 1.36 0.72 ± 0.12 1.29 ± 0.18 1.83 ± 0.37
0.001** 0.001** 0.001** 0.001** 0.001** 0.001** 0.001**
Comparing the different antepartum fetal surveillance parameters for adverse perinatal outcome, AFV with cut-off point ¼ 2 cm and MCA-PI with cut-off at 1 had the best sensitivity (77.72% and 77.27%, respectively), CPR with cut-off point 1.05 had the best specificity (98.2%), CPR had best positive predictive value (PPV) (97.05%) and AFV had best negative predictive value (NPV) (83.6%) (Table 8).
**p50.001. highly significant. Table 3. Comparison between both groups as regards the amniotic fluid volume and BPP.
Parameter Normal AFV Oligohydraminos BPP frequency (%) 0/8 2/8 4/8 6/8 8/8 Total
Adverse (n ¼ 44)
Normal (n ¼ 56)
10 (22.7%) 34 (77.3%)
51 (91.1%) 5 (8.9%)
3 7 20 10 4 44
0 0 6 8 42 56
(6.8) (15.9) (45.6) (22.7) (9) (100)
p value 0.001**
(0) (0) (10.7) (14.3) (75) (100)
**p50.001, highly significant.
ratio and higher UA-PI when compared to the normal outcome group with statistically highly significant differences between both groups (Table 2). The percentage of women with oligohydraminos and low BPP in adverse outcome group was higher than that compared to the group of normal outcome with statistically highly significant difference between both groups (Table 3). The adverse outcome group had a higher rate of cesarean section mostly due to fetal distress and higher rate of induced VD due to oligohydraminos compared to the normal outcome group (Table 4). The period of gestation was directly related to incidence of fetal distress and NICU admission but not affecting mean NBW, MSL, Apgar scores or meconium aspiration (Table 5). The rate of CS for fetal distress and adverse perinatal outcome was higher in women with abnormal UA-PI, MCA-PI and MCA-PI/UA-PI ratio and low BPP 4/8 and women with oligohydramnios compared to the normal group (Tables 6 and 7).
Comments Our study concluded that women with adverse neonatal outcome had higher UA-PI and lower MCA-PI, MCA-PI:UAPI ratio, GA (by US), AFV, BPP, EFW, NBW when compared to those with normal perinatal outcome. We found also that women with adverse neonatal outcome had a higher rate of cesarean section mostly due to fetal distress and higher rate of induced VD due to oligohydraminos compared to the normal outcome group. Women with adverse perinatal outcome showed lower MCA-PI (0.92 versus 1.29), MCA-PI:UA-PI ratio (1.04 versus 1.83), lower US assessed GA (37.82 versus 39.48), lower NBW (2705 versus 3108), BPP (4.55 versus 7.21) when compared to women with normal perinatal outcome. They also had higher cases with oligohydramnios (34 versus 5), and higher UA-PI (0.89 versus 0.72). We also found that all assessment parameters used in our study were related significantly to both perinatal outcome and mode of delivery. In the current study, we found that the rate of cesarean section among all patients was 56%. This agrees with Freeman et al. and Tasic et al. who documented increased cesarean section rates in case of prolonged pregnancy [13,19]. In this study, we found that the risk of adverse perinatal outcome increase with increasing the period of gestation. These results agree with Caughey et al. who noticed the incidence of adverse neonatal outcomes at 40, 41 and 42 weeks. They found that the risk of meconium aspiration increased significantly from 2.18 at 40 weeks to 3.35 at 41 weeks and 4.09 at 42 weeks [20]. Martina Delaney et al. found that GA 41 weeks had increased incidence of perinatal complications as follows: fetal distress and meconium staining liquor [21]. Jamal et al. reported that low BPP was associated with increased risk of cesarean section [22].
Doppler in pregnancy 40 weeks plus
DOI: 10.3109/14767058.2014.892068
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Table 5. Relation between the period of gestation at delivery and\& adverse perinatal outcome. Mean Apgar score
Mean Apgar score
Period of gestation
No.
%
Mean NBW (kg)
Fetal distress (No.)
MSL (No.)
1 min
5 min
MAS (No.)
NICU (No.)
280–287 288–294
16 28
36 64
2765.93 2676.42
11 14
6 10
7 6
8 7
1 3
1 5
Table 6. Relation between UA-PI, MCA-PI and MCA-PI/UA-PI ratio (CPR) to perinatal outcome and the mode of delivery. UA- PI
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Normal 50.82 (n ¼ 57) Vaginal delivery CS for fetal distress Other indications of CS Total no. of adverse outcome Total no. of normal outcome
29 7 21 14 43
(50.9%) (12.3%) (36.8%) (24.6%) (75.4%)
MCA-PI
Abnormal 0.82 (n ¼ 43) 15 18 10 30 13
p value
(34.9%) (41.9%) (23.3%) (69.8%) (30.2%)
0.003** 0.001**
Normal 41.0 (n ¼ 59) 29 9 21 10 49
(49.2%) (15.3%) (35.6%) (16.9%) (83.1%)
MCA-PI:UA-PI ratio (CPR)
Abnormal 1.0 (n ¼ 41) 15 16 10 34 7
p value
(36.6%) (39%) (24.4%) (82.9%) (17.1%)
0.003** 0.001**
Normal 41.05 (n ¼ 66) 33 8 25 11 55
(55%) (12.1%) (37.9%) (16.7%) (83.3%)
Abnormal 1.05 (n ¼ 34) 11 17 6 33 1
(32.4%) (50%) (17.6%) (97.1%) (2.9%)
p value 0.001** 0.001**
**p50.001, highly significant. Table 7. Relation between BPP, amniotic fluid volume to perinatal outcome and the mode of delivery. BPP
Vaginal delivery CS for fetal distress Other indications of CS Total no. of adverse outcome Total no. of normal outcome
BPP 44/8 (n ¼ 66)
BPP 4/8 (n ¼ 34)
33 8 25 16 50
11 17 6 28 6
(50%) (12.1%) (37.9%) (24.2%) (75.8%)
(32.4%) (50%) (17.6%) (82.4%) (17.6%)
AFV* p value 0.001** 0.001**
Normal AFV (n ¼ 61) 33 5 23 10 51
(54.1%) (8.2%) (37.7%) (16.4%) (83.6%)
Oligohydraminos (n ¼ 39) 11 20 8 34 5
(28.2%) (51.3%) (20.5%) (87.2%) (12.8%)
p value 0.001** 0.001**
Oligohydraminos was taken into consideration when the maximal vertical pocket diameter was 2 cm as considered by Dasari et al. [23]. **p50.001, highly significant. Table 8. The performance of the different testing parameters. Parameter BPP Amniotic fluid volume Umbilical PI MCA-PI CPR
Area under curve
Cut-off
Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)
0.855 0.847 0.839 0.905 0.963
4/8 2 0.82 1.0 1.05
63.64 77.72 68.18 77.27 75
89.28 91.1 76.78 87.5 98.2
82.35 87.18 69.77 82.9 97.05
75.76 83.6 75.44 83.05 83.3
In the current study, 39% of women had oligohydraminos, 87.2% of them had adverse perinatal outcome. Also, there was a significant association between oligohydraminos and increased rate of cesarean section especially for intrapartum fetal distress. The present results magnified the importance of close observation of the pregnant women with suspected oligohydraminos. Oligohydraminos is associated with increased risk of adverse outcome and fetal distress. Once oligohydraminos is present, there is a higher incidence of fetal distress [23]. However, Ott et al. reported that AFV is a weaker predictor of poor perinatal outcome. However, they classified women into high and low risks not focusing on postdate pregnancy [24]. In the current study, AFV assessment showed a sensitivity of 77.72%, a specificity of 91.1%, PPV of 87.18% and NPV
of 83.6%. Hassan found that the sensitivity was 63.2% and the specificity was 83% [25]. On considering the cut-off point of 0.82 for UA-PI, operative interference due to fetal distress and presence of adverse outcome were found to be significantly higher in the adverse group compared to the normal group [26]. Evaluation of performance of the UA-PI assessment test in the current study revealed that it was of sensitivity of 68.18%, specificity of 76.78%, PPV of 69.77% and NPV of 75.44%. Dubinsky et al. reported that the sensitivity of UA Doppler velocimetry was about 64% [27]. On considering the cut-off point of 1.0 [15], adverse perinatal outcome and cesarean delivery due to fetal distress was found to be significantly higher in the adverse group than in the normal group.
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Lam et al. found that MCA-PI is better than UA-PI and AFV assessment to predict the adverse outcome in uncomplicated postdated pregnancy [28]. However, Usha et al. discovered absence of any significant statistical difference in UA-PI and MCA-PI in predicting adverse perinatal outcome. They attributed this to that the mechanism of fetal compromise is due to decrease in the flow of nutrients across the placenta and decrease in the efficiency of utilization of nutrients by the placenta and the fetus. These changes are not reflected in increase in resistance in the blood vessels of placenta or fetus [29]. Evaluation of performance of the MCA-PI assessment test in the current study revealed that it was of sensitivity of 77.27%, specificity of 87.5%, PPV of 82.9% and NPV of 83.05%. On considering the CPR (MCA-PI/UA-PI) with a cut-off point of 1.05 [16], adverse perinatal outcome and cesarean delivery due to fetal distress was found to be significantly higher in the abnormal group than in the normal group. CPR is a better predictor of fetal compromise than neither MCA-PI nor UA-PI alone [30]. CPR assessment in the current study revealed a sensitivity of 75%, a specificity of 98.2%, PPV of 97.05% and NPV of 83.3%. Devine et al. found that it can predict the adverse perinatal outcome with sensitivity of 80% and specificity of 95% [16]. In contrast, Shahina Bano et al. used a cut-off value of 1.08 which had a higher sensitivity and specificity when compared with UA-PI and MCA-PI [31]. Susumu et al. found that CPR with cut-off value of 1.1 had 62% sensitivity and 74.5% specificity to predict adverse outcome [32]. To the best of our knowledge, our study is the first one evaluating all five assessment parameters in evaluation of pregnancies from 40 to 42 weeks regarding both neonatal outcome and route of delivery. In this study, CPR showed the highest specificity (98.2%) in comparison with other parameters followed by AFV (91.1%). However, AFV showed the highest sensitivity (77.72%) followed by MCA-PI (77.27%). So we recommend weekly measurement of Doppler waveforms from the ratio of the MCA and UA combined with the assessment of amniotic fluid volume appear to provide a reliable method of establishing fetal health in pregnancies from 40 to 42 weeks.
Declaration of interest No conflict of interest.
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ORIGINAL ARTICLE
Fetal middle cerebral and umbilical artery Doppler after 40 weeks gestational age
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Ahmed M. Maged, Aly Abdelhafez, Walaa AI Mostafa, and Wael Elsherbiny Obstetrics and Gynecology Department, Kasr Aini Hospital, Cairo University, Cairo, Egypt
Abstract
Keywords
Objective: To determine the value of fetal Doppler indices named middle cerebral artery (MCA)-PI, umbilical artery (UA)-PI and MCA-PI/UA-PI ratio, and amniotic fluid volume assessment in pregnancies 280–294 d and their correlation with the mode of delivery and perinatal outcome. Study design: Prospective observational study conducted on 100 whose gestational age (GA) from 40 to 42 weeks. MCA and UA Doppler and MCA-PI/UA-PI ratio, amniotic fluid volume (AFV) were assessed. They were divided into two groups based on the presence or absence of adverse perinatal outcome. Results: Women with adverse perinatal outcome showed lower MCA-PI (0.92 versus 1.29), MCA-PI:UA-PI ratio (1.04 versus 1.83), lower gestational age when assessed by ultrasound (37.82 versus 39.48 weeks), lower neonatal birth weight (2705 versus 3108 g), fetal biophysical profile (BPP) (4.55 versus 7.21) when compared to women with normal perinatal outcome. They also had higher cases with oligohydramnios (34 versus 5), and higher UA-PI (0.89 versus 0.72). Conclusion: Women with adverse neonatal outcome had higher UA-PI and lower MCA-PI, MCA-PI:UA-PI ratio, GA (by US), AFV, BPP, estimated fetal weight, neonatal birth weight when compared to those with normal perinatal outcome. Women with adverse neonatal outcome had a higher rate of cesarean section mostly due to fetal distress and induced VD due to oligohydraminos compared to the normal outcome group.
Amniotic fluid volume, Doppler velocimetry, mode of delivery, perinatal outcome
Introduction The international definition of prolonged pregnancy is 42 completed weeks (294 days) or more from the first day of the last menstrual period [1]. The incidence of postterm pregnancy ranges from 4% to 19% [2]. MacDorman and Kirmeyer reported increased perinatal mortality rate if pregnancy exceeded 41 weeks [3]. The major causes of fetal death include gestational hypertension, prolonged labor with cephalopelvic disproportion, ‘‘unexplained anoxia’’ and malformations [4]. Children born postterm have more developmental abnormalities compared with those born before 42 weeks [5]. The problems of prolonged pregnancy can be decreased by routine antepartum fetal surveillance prior to onset of spontaneous labor [6]. A safe limit for continuation of pregnancy beyond expected date of delivery cannot be established. Some suggested that risk of postmaturity starts at 40 weeks [7]. ACOG suggested that initiation of fetal surveillance at 41 weeks is a reasonable option [1]. Address for correspondence: Ahmed Mohamed Maged, Department of Obstetrics and Gynecology, Kasr Aini Hospital, Cairo University, 135 King Faisal Street Haram Giza, Postal code 12151, Cairo, Egypt. Tel: +01005227404. Fax: 35873103. E-mail: [email protected]
History Received 29 October 2013 Revised 20 January 2014 Accepted 4 February 2014 Published online 27 February 2014
Fetal Doppler velocimetry has been used as a good parameter for assessment of fetal well-being. A large experience with this technique has been reported with respect to the prediction of the fetus at risk of developing IUGR, antepartum and intrapartum fetal asphyxia, and neonatal morbidity [8]. Several studies indicated that Doppler indices may be powerful predictors of adverse perinatal outcome in complicated pregnancies [9]. The aim of this study was to determine the value of fetal Doppler indices named middle cerebral artery (MCA)-PI, umbilical artery (UA)-PI and MCA-PI/UA-PI ratio, and amniotic fluid volume assessment in pregnancies 40–42 weeks’ gestation and their relation with the mode of delivery and perinatal outcome.
Materials and methods This prospective observational study was carried out on 100 women whose gestational age (GA) was 40–42 weeks’ gestation attending the antenatal clinic of Kasr AL-Aini Maternity Hospital from December 2009 to July 2012. The study was approved by local ethics committee, and an informed oral consent was obtained from all participants. Inclusion criteria included singleton living fetuses with vertex presentation. An accurate estimation of GA (from 280 to 294 d) was calculated from the first day of regular last
Doppler in pregnancy 40 weeks plus
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DOI: 10.3109/14767058.2014.892068
menstrual period and confirmed or modified by an early ultrasound examination before 20 weeks gestation. Exclusion criteria included cases with premature rupture of membranes, antepartum hemorrhage, patients in labor and maternal medical disorders as hypertension, diabetes mellitus, hepatic, cardiac, renal or anemia with pregnancy. Patients with a uterine scar or any condition contraindicating induction of labor were also excluded. All patients were subjected to detailed history taking, physical examination and routine investigations including complete blood picture, RH typing, fasting blood sugar, liver functions, kidney functions and urine analysis. Ultrasound and Doppler study was done twice weekly till the onset of labor or termination of pregnancy in order to assess GA, estimated fetal weight (EFW), placental site and grading, amniotic fluid volume (AFV) (oligohydraminos was diagnosed if the largest vertical pocket 2 cm), Doppler study of the MCA and UA and modified fetal biophysical profile (BPP) scoring system. Transabdominal ultrasound was performed while woman was in a slightly tilted position with the head of the bed raised 30 and a small pillow under the right loin. The apparatus used was the Voluson ProV GE ultrasound machine (GE Shareowner Company Fairfield, Piscataway, NJ) with Doppler unit and convex linear transducer 3.5 MHz. GA determination was done by assessment of biparietal diameter, femur length and abdominal circumference. Fetal weight estimation was detected according to Hadlock using the head, abdomen and femur measurements [10]. Fetal-modified BPP scoring: four fetal biophysical variables: fetal breathing movements, gross body movements, fetal tone, qualitative amniotic fluid volume were measured. The duration of observation was extended until each variable met normal criteria or 30 min period has passed. During each observation period, each variable was scored as 2 or 0 score. A score 4 was considered abnormal [11]. UA Doppler was done while the patient placed in a semirecumbent position with a left lateral tilt and the uterine contents are scanned to select an area of amniotic cavity with several loops of umbilical cord. Ideally these cord loops should not be close to the cord insertion [12]. Then, using a pulsed wave Doppler on a free loop of cord, the characteristic sound and shape of the UA was identified. A minimum of three separate readings were averaged before the final values were obtained. Recording was performed during periods of fetal apnea. Cut-off point used in this study for PI was 0.82 [13]. The standard plane for measuring MCA Doppler is the transthalamic plane which contains the thalami and cavum septum pellucidum. The MCA can be seen pulsating at the level of origin of the circle of Willis. Care was taken not to exert pressure on the fetal head because this alters the flow velocity waveforms from the MCA [14]. Cut-off point used in this study for PI was 1.0 [15]. The cerebro-placental ratio (CPR) was calculated. Cut-off point used in this study for CPR is 1.05 [16]. Spontaneous vaginal delivery was awaited, but induction of delivery was commenced if there is oligohydraminos, BPP is 6 or if the period of gestation extended beyond 42 weeks.
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With a Bishop score 47, labor was induced by oxytocin infusion (47%) (starting with 5 IU in 500 ml Ringer solution and the dose rate increased according to the response) and/or artificial amniotomy (15%). Oxytocin (Syntocinon, 5 IU ampoules, Novartis Pharma, Amiria, Cairo, Egypt). Otherwise, cervical ripening was induced with one tablet of transvaginal prostaglandins E1 (Vagiprost, 25 mg tablets, ADWIA Pharmaceuticals, Amiria, Cairo, Egypt). (10%) the patient was reassessed after 6 h and received another dose if required. FHS was auscultated every 15 min using fetal Doppler, and once in the active stage of labor (cervical dilatation 43 cm), amniotomy was performed and liquor was observed for meconium staining. Cardiotocography (CTG) was done for 20 min before the induction of labor. CTG was repeated when needed during the induction. CTG tracing was considered abnormal when there was persistent late decelerations or persistent variable decelerations and diminished FHR variability (55 bpm). These cases were terminated by CS. The study population was divided into two groups based on the presence or absence of adverse perinatal outcome. Adverse perinatal outcome was defined as the presence of one or more of the following: Cesarean delivery for fetal distress, Apgar score 57 at 1 and 5 min, meconium aspiration syndrome (MAS) or neonatal intensive care unit (NICU) admission. MAS was diagnosed with the visual observation of greenish fluid discoloration with respiratory difficulties and an evidence of over-expansion and widespread coarse infiltration of the lungs on chest X-ray [17]. Fetus/neonate was considered to be distress if any one of the following was present: [18] (1) Ominous FHR changes led to caesarean section (LSCS) or forceps/ventouse delivery. (2) Presence of moderate–thick meconium stained liquor (MSL). (3) Apgar score at 5 min 57. (4) Umbilical cord arterial blood pH57.2. (5) Admission into NICU for birth asphyxia. (6) Neonatal seizures within first 24–48 h. (7) Incidence of intrapartum/neonatal mortality. Data were collected, verified and revised. Continuous data were expressed as means ± standard deviation. Categorical data were presented in the form of number and percentage. Comparison between the two groups was performed using student unpaired t test and chi-square test. ROC curve was used to determine the sensitivity and specificity of the different Doppler techniques. The data were considered significant if p values was 0.05, highly significant if p50.01. Statistical analysis was performed with the aid of the SPSS computer program (version 12 windows, SPSS Inc., Chicago, IL).
Results There was no statistically significant difference between the two groups as regards the maternal age, height, weight, gravidity, parity or GA at time of testing (Table 1). The adverse outcome group had lower GA (by US), EFW, neonatal birth weight, BPP, MCA-PI and MCA-PI:UA-PI
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Table 1. Demographic data of the two studied groups.
Parameter Maternal age (years) Maternal height (cm) Maternal weight (kg) GA at delivery (d) Gravidity Parity
Adverse (n ¼ 44) 25.02 ± 4.22 160.25 ± 3.81 79.18 ± 6.09 283.07 ± 39.41 1.07 ± 1.49 0.59 ± 0.97
Normal (n ¼ 56) 25.29 ± 3.64 159.32 ± 3.97 76.98 ± 6.74 281.66 ± 34.79 1.02 ± 1.45 0.59 ± 0.91
Table 4. Comparison between both groups as regards the mode of delivery, indications of CS and indications of induced VD. p value NS
0.739 0.240NS 0.094NS 0.850NS 0.865NS 0.993NS
NS, not significant (p40.05).
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Table 2. Comparison between both groups as regards: GA, BPP, UA-PI, MCA-PI, MCA-PI:UA-PI ratio and EFW.
Parameter GA US (weeks) EFW (g) Neonatal birthweight BBP UA-PI MCA-PI MCA-PI:UA-PI ratio
Parameter CS Induced VD Spontaneous VD Indications of CS Failed induction Failure of progress Fetal distress Indications of induced VD BPP56/8 Oligohydraminos Reaching 42 weeks
Adverse (n ¼ 44)
Normal (n ¼ 56)
31 (70.5%) 10 (22.7%) 3 (6.8%)
25 (44.6%) 11 (19.6%) 20 (35.7%)
0.002**
5 (16.1%) 1 (3.2%) 25 (80.6%)
9 (36.0%) 16 (64.0%) 0 (0%)
0.001**
1 (10%) 9 (90%) 0 (0%)
7 (63.6%) 2 (18.2%) 2 (18.2%)
0.004**
p value
**p50.001, highly significant.
Adverse (n ¼ 44)
Normal (n ¼ 56)
p value
37.82 ± 0.87 2798.41 ± 28 2705.34 ± 29 4.55 ± 1.85 0.89 ± 0.12 0.92 ± 0.18 1.04 ± 0.19
39.48 ± 0.91 3221.25 ± 32 3108.21 ± 31 7.21 ± 1.36 0.72 ± 0.12 1.29 ± 0.18 1.83 ± 0.37
0.001** 0.001** 0.001** 0.001** 0.001** 0.001** 0.001**
Comparing the different antepartum fetal surveillance parameters for adverse perinatal outcome, AFV with cut-off point ¼ 2 cm and MCA-PI with cut-off at 1 had the best sensitivity (77.72% and 77.27%, respectively), CPR with cut-off point 1.05 had the best specificity (98.2%), CPR had best positive predictive value (PPV) (97.05%) and AFV had best negative predictive value (NPV) (83.6%) (Table 8).
**p50.001. highly significant. Table 3. Comparison between both groups as regards the amniotic fluid volume and BPP.
Parameter Normal AFV Oligohydraminos BPP frequency (%) 0/8 2/8 4/8 6/8 8/8 Total
Adverse (n ¼ 44)
Normal (n ¼ 56)
10 (22.7%) 34 (77.3%)
51 (91.1%) 5 (8.9%)
3 7 20 10 4 44
0 0 6 8 42 56
(6.8) (15.9) (45.6) (22.7) (9) (100)
p value 0.001**
(0) (0) (10.7) (14.3) (75) (100)
**p50.001, highly significant.
ratio and higher UA-PI when compared to the normal outcome group with statistically highly significant differences between both groups (Table 2). The percentage of women with oligohydraminos and low BPP in adverse outcome group was higher than that compared to the group of normal outcome with statistically highly significant difference between both groups (Table 3). The adverse outcome group had a higher rate of cesarean section mostly due to fetal distress and higher rate of induced VD due to oligohydraminos compared to the normal outcome group (Table 4). The period of gestation was directly related to incidence of fetal distress and NICU admission but not affecting mean NBW, MSL, Apgar scores or meconium aspiration (Table 5). The rate of CS for fetal distress and adverse perinatal outcome was higher in women with abnormal UA-PI, MCA-PI and MCA-PI/UA-PI ratio and low BPP 4/8 and women with oligohydramnios compared to the normal group (Tables 6 and 7).
Comments Our study concluded that women with adverse neonatal outcome had higher UA-PI and lower MCA-PI, MCA-PI:UAPI ratio, GA (by US), AFV, BPP, EFW, NBW when compared to those with normal perinatal outcome. We found also that women with adverse neonatal outcome had a higher rate of cesarean section mostly due to fetal distress and higher rate of induced VD due to oligohydraminos compared to the normal outcome group. Women with adverse perinatal outcome showed lower MCA-PI (0.92 versus 1.29), MCA-PI:UA-PI ratio (1.04 versus 1.83), lower US assessed GA (37.82 versus 39.48), lower NBW (2705 versus 3108), BPP (4.55 versus 7.21) when compared to women with normal perinatal outcome. They also had higher cases with oligohydramnios (34 versus 5), and higher UA-PI (0.89 versus 0.72). We also found that all assessment parameters used in our study were related significantly to both perinatal outcome and mode of delivery. In the current study, we found that the rate of cesarean section among all patients was 56%. This agrees with Freeman et al. and Tasic et al. who documented increased cesarean section rates in case of prolonged pregnancy [13,19]. In this study, we found that the risk of adverse perinatal outcome increase with increasing the period of gestation. These results agree with Caughey et al. who noticed the incidence of adverse neonatal outcomes at 40, 41 and 42 weeks. They found that the risk of meconium aspiration increased significantly from 2.18 at 40 weeks to 3.35 at 41 weeks and 4.09 at 42 weeks [20]. Martina Delaney et al. found that GA 41 weeks had increased incidence of perinatal complications as follows: fetal distress and meconium staining liquor [21]. Jamal et al. reported that low BPP was associated with increased risk of cesarean section [22].
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Table 5. Relation between the period of gestation at delivery and\& adverse perinatal outcome. Mean Apgar score
Mean Apgar score
Period of gestation
No.
%
Mean NBW (kg)
Fetal distress (No.)
MSL (No.)
1 min
5 min
MAS (No.)
NICU (No.)
280–287 288–294
16 28
36 64
2765.93 2676.42
11 14
6 10
7 6
8 7
1 3
1 5
Table 6. Relation between UA-PI, MCA-PI and MCA-PI/UA-PI ratio (CPR) to perinatal outcome and the mode of delivery. UA- PI
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Normal 50.82 (n ¼ 57) Vaginal delivery CS for fetal distress Other indications of CS Total no. of adverse outcome Total no. of normal outcome
29 7 21 14 43
(50.9%) (12.3%) (36.8%) (24.6%) (75.4%)
MCA-PI
Abnormal 0.82 (n ¼ 43) 15 18 10 30 13
p value
(34.9%) (41.9%) (23.3%) (69.8%) (30.2%)
0.003** 0.001**
Normal 41.0 (n ¼ 59) 29 9 21 10 49
(49.2%) (15.3%) (35.6%) (16.9%) (83.1%)
MCA-PI:UA-PI ratio (CPR)
Abnormal 1.0 (n ¼ 41) 15 16 10 34 7
p value
(36.6%) (39%) (24.4%) (82.9%) (17.1%)
0.003** 0.001**
Normal 41.05 (n ¼ 66) 33 8 25 11 55
(55%) (12.1%) (37.9%) (16.7%) (83.3%)
Abnormal 1.05 (n ¼ 34) 11 17 6 33 1
(32.4%) (50%) (17.6%) (97.1%) (2.9%)
p value 0.001** 0.001**
**p50.001, highly significant. Table 7. Relation between BPP, amniotic fluid volume to perinatal outcome and the mode of delivery. BPP
Vaginal delivery CS for fetal distress Other indications of CS Total no. of adverse outcome Total no. of normal outcome
BPP 44/8 (n ¼ 66)
BPP 4/8 (n ¼ 34)
33 8 25 16 50
11 17 6 28 6
(50%) (12.1%) (37.9%) (24.2%) (75.8%)
(32.4%) (50%) (17.6%) (82.4%) (17.6%)
AFV* p value 0.001** 0.001**
Normal AFV (n ¼ 61) 33 5 23 10 51
(54.1%) (8.2%) (37.7%) (16.4%) (83.6%)
Oligohydraminos (n ¼ 39) 11 20 8 34 5
(28.2%) (51.3%) (20.5%) (87.2%) (12.8%)
p value 0.001** 0.001**
Oligohydraminos was taken into consideration when the maximal vertical pocket diameter was 2 cm as considered by Dasari et al. [23]. **p50.001, highly significant. Table 8. The performance of the different testing parameters. Parameter BPP Amniotic fluid volume Umbilical PI MCA-PI CPR
Area under curve
Cut-off
Sensitivity (%)
Specificity (%)
PPV (%)
NPV (%)
0.855 0.847 0.839 0.905 0.963
4/8 2 0.82 1.0 1.05
63.64 77.72 68.18 77.27 75
89.28 91.1 76.78 87.5 98.2
82.35 87.18 69.77 82.9 97.05
75.76 83.6 75.44 83.05 83.3
In the current study, 39% of women had oligohydraminos, 87.2% of them had adverse perinatal outcome. Also, there was a significant association between oligohydraminos and increased rate of cesarean section especially for intrapartum fetal distress. The present results magnified the importance of close observation of the pregnant women with suspected oligohydraminos. Oligohydraminos is associated with increased risk of adverse outcome and fetal distress. Once oligohydraminos is present, there is a higher incidence of fetal distress [23]. However, Ott et al. reported that AFV is a weaker predictor of poor perinatal outcome. However, they classified women into high and low risks not focusing on postdate pregnancy [24]. In the current study, AFV assessment showed a sensitivity of 77.72%, a specificity of 91.1%, PPV of 87.18% and NPV
of 83.6%. Hassan found that the sensitivity was 63.2% and the specificity was 83% [25]. On considering the cut-off point of 0.82 for UA-PI, operative interference due to fetal distress and presence of adverse outcome were found to be significantly higher in the adverse group compared to the normal group [26]. Evaluation of performance of the UA-PI assessment test in the current study revealed that it was of sensitivity of 68.18%, specificity of 76.78%, PPV of 69.77% and NPV of 75.44%. Dubinsky et al. reported that the sensitivity of UA Doppler velocimetry was about 64% [27]. On considering the cut-off point of 1.0 [15], adverse perinatal outcome and cesarean delivery due to fetal distress was found to be significantly higher in the adverse group than in the normal group.
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Lam et al. found that MCA-PI is better than UA-PI and AFV assessment to predict the adverse outcome in uncomplicated postdated pregnancy [28]. However, Usha et al. discovered absence of any significant statistical difference in UA-PI and MCA-PI in predicting adverse perinatal outcome. They attributed this to that the mechanism of fetal compromise is due to decrease in the flow of nutrients across the placenta and decrease in the efficiency of utilization of nutrients by the placenta and the fetus. These changes are not reflected in increase in resistance in the blood vessels of placenta or fetus [29]. Evaluation of performance of the MCA-PI assessment test in the current study revealed that it was of sensitivity of 77.27%, specificity of 87.5%, PPV of 82.9% and NPV of 83.05%. On considering the CPR (MCA-PI/UA-PI) with a cut-off point of 1.05 [16], adverse perinatal outcome and cesarean delivery due to fetal distress was found to be significantly higher in the abnormal group than in the normal group. CPR is a better predictor of fetal compromise than neither MCA-PI nor UA-PI alone [30]. CPR assessment in the current study revealed a sensitivity of 75%, a specificity of 98.2%, PPV of 97.05% and NPV of 83.3%. Devine et al. found that it can predict the adverse perinatal outcome with sensitivity of 80% and specificity of 95% [16]. In contrast, Shahina Bano et al. used a cut-off value of 1.08 which had a higher sensitivity and specificity when compared with UA-PI and MCA-PI [31]. Susumu et al. found that CPR with cut-off value of 1.1 had 62% sensitivity and 74.5% specificity to predict adverse outcome [32]. To the best of our knowledge, our study is the first one evaluating all five assessment parameters in evaluation of pregnancies from 40 to 42 weeks regarding both neonatal outcome and route of delivery. In this study, CPR showed the highest specificity (98.2%) in comparison with other parameters followed by AFV (91.1%). However, AFV showed the highest sensitivity (77.72%) followed by MCA-PI (77.27%). So we recommend weekly measurement of Doppler waveforms from the ratio of the MCA and UA combined with the assessment of amniotic fluid volume appear to provide a reliable method of establishing fetal health in pregnancies from 40 to 42 weeks.
Declaration of interest No conflict of interest.
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