ASSESSMENT OF UTERINE ARTERY, UMBILICAL ARTERY AND FETAL MCA DOPPLER VELOCIMETRY AS PREDICTORS OF ADVERSE OUTCOME IN PREGNANCIES COMPLICATED BY THIRD TRIMESTER OLIGOHYDRAMNIOS

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ASSESSMENT OF UTERINE ARTERY, UMBILICAL ARTERY
AND FETAL MCA DOPPLER VELOCIMETRY AS PREDICTORS
OF ADVERSE OUTCOME IN PREGNANCIES COMPLICATED BY
THIRD TRIMESTER OLIGOHYDRAMNIOS

• ABSTRACT ID NO1058

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INTRODUCTION

• Oligohydramnios occurs in about 3-5 of all
  pregnancies, more commonly in the third
  trimester.
• Has a strong association with increased risk for
  perinatal morbidity and mortality.
• Adverse outcomes associated with oligohydramnios
  are-
• IGUR
• Structural abnormalities
• Dysmaturity syndrome
• Pulmonary hypoplasia
• Fetal distress during labour
• Contracture of joints
• Cord compression
• Etiology is multifactorial, but a major factor is
  uteroplacental insufficiency.

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• UTEROPLACENTAL INSUFFICIENCY
• CHRONIC FETAL HYPOXIA
• REDISTRIBUTION OF FETAL CARDIAC OUTPUT
• DECREASED BLOOD SUPPLY TO MAJOR
  SOURCES OF AMNIOTIC FLUID PRODUCTION
• 
  
• OLIGOHYDRAMNIOS
  

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• Not all pregnancies complicated with
  oligohydramnios develop adverse outcomes.
• Traditional methods of evaluation do not help to
  reliably distinguish those with normal and
  adverse outcomes, resulting in aggressive
  management of all cases.
• Fetal and maternal Doppler evaluation may provide
  insight into the development of oligohydramnios
  since the major etiological factor is thought to
  be fetal hypoxia due to uteroplacental
  insufficiency.
• The purpose of this study is to establish the
  predictive value of Doppler velocimetry in
  identifying pregnancies complicated with
  oligohydramnios that are at increased risk of
  developing adverse perinatal outcomes to ensure a
  heightened regimen of antenatal surveillance and
  management to reduce the incidence of further
  compromise and identify cases that may require
  prompt termination. 

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AIMS AND OBJECTIVES

• To evaluate Doppler velocimetry of uterine
  artery, umbilical artery and fetal MCA as
  predictors of adverse outcomes in pregnancies
  complicated by third trimester oligohydramnios.
  
• To identify which Doppler indices are more
  sensitive and specific in identifying fetuses at
  risk of developing adverse outcomes.
• To evaluate the incidence of adverse outcomes in
  borderline and severe oligohydramnios.

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MATERIALS AND METHODS

• Our study was conducted in 30 patients diagnosed
  with oligohydramnios in the third trimester of
  pregnancy at our hospital.

INCLUSION CRITERIA All pregnant women irrespective of gravida beyond 24 weeks of gestation with oligohydramnios AFI lt 5 cm and borderline oligohydramnios AFI lt 5-8 cm. Singleton pregnancy. Intact membranes. EXCLUSION CRITERIA Pregnancies complicated by fetal anomalies (structural or chromosomal). Multiple pregnancy. Patients with hypertension, diabetes, Rh incompatibility.
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• WOMEN FULFILLING THE CRITERIA
• AFI ESTIMATION BORDERLINE/SEVERE
• OLIGOHYDRAMNIOS
• DOPPLER VELOCIMETRY OF UTERINE
  ARTERIES, UMBILICAL ARTERY AND FETAL MCA
• FOLLOW UP TILL DELIVERY
  
• 
  

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• All patients were followed up until after
  delivery with NST, BPP, FHRM. At the time of
  delivery, gestational age ,mode of delivery,
  indication for LSCS, fetal heart rate, nature of
  amniotic fluid, APGAR score, Birth weight and
  NICU admission were all taken into account as
  parameters for identifying adverse outcomes.
• The following parameters were considered as
  adverse perinatal outcomes
• Preterm delivery
• Caesarean section
• Fetal distress
• Meconium stained liquor
• APGAR score lt6 at 1 min, lt7 at 5 min
• Low birth weight (lt 10th percentile for
  gestational age)
• Still birth
• NICU admission

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• For Doppler velocimetry, the following parameters
  were considered abnormal
• In the uterine artery RI,PI gt95th percentile
  for gestational age.
• Presence of
  diastolic notch.
• In the umbilical artery RI,PI,S/D RATIOgt 95th
  percentile.
• 
  Absent/Reversed end diastolic flow
• In the fetal MCA RI,PI lt 5th percentile
  for gestational age.
• S/D ratio lt
  gestational age
• MCA PI/
  Umbilical artery PI ratio lt 1.08.
• Statistical analysis
• - Sensitivity, specificity, positive and negative
  predictive value for each of the Doppler indices.
• - Chi-Square / Fischer test for significance.

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CASE NO-1
FIG- 1
FIG -2
FIG-3
This patient had borderline oligohydramnios
(FIG-1), but a normal Doppler study. Both uterine
arteries had normal low impedance flow (FIG-23).
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FIG - 4
FIG - 5
Umbilical artery showed normal low impedance flow
(FIG-4). Fetal MCA showed normal high impedance
flow pattern (FIG-5).
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CASE NO -2
FIG -6
FIG -7
This patient also had borderline oligohydramnios
(FIG-6) but the Doppler study was abnormal. The
uterine arteries showed normal low impedance flow
(FIG-7).
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FIG -8
FIG -9
The umbilical artery showed increased impedance
with absent end-diastolic flow (FIG-8) while the
fetal MCA showed normal high impedance flow
(FIG-9).
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CASE NO -3
FIG - 10
FIG - 11
This patient had almost no liquor. The uterine
arteries showed increased impedance with
persistent diastolic notch (FIG 1011).
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FIG -12
FIG -13
The umbilical artery showed high impedance flow
with reduced end diastolic flow (FIG-12). The
fetal MCA showed reduced RI with increased
diastolic flow suggestive of brain sparing reflex
(FIG-13).
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RESULTS

• Majority of patients were primigravida (66.7).
• Among 30 patients, 53.3 had Borderline
  oligohydramnios and 46.7 had severe
  oligohydramnios.
• There was increased incidence of adverse outcomes
  in severe oligohydramnios than borderline
  oligohydramnios (92.8 vs.75).
• In the study by Ravikant et al(7) ,there was an
  increase in LSCS in borderline oligohydramnios
  than in severe oligohydramnios (90.48 vs.
  40.82). But in our study, there was increased
  LSCS in severe oligohydramnios than in borderline
  oligohydramnios.
• Among those patients who underwent LSCS, 47.1
  was for fetal distress and 23.5 was for severe
  oligohydramnios, while in the study by Ravikant
  et al, 20.52 was for fetal distress and 41.02
  was for severe oligohydramnios.

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TABLE COMPARING THE INCIDENCE OF ADVERSE OUTCOMES
IN OUR STUDY WITH SIMILAR STUDIES CONDUCTED IN
INDIA
Adverse outcomes Jandial et al(6) Ravikant et al(7) Our study
Induction of labour 58 --- 16
LSCS for FD 42 26.52 47.1
Preterm delivery 35 30 6.7
IUGR 58 34.29 43.3
NICU admission 16 25.72 36.7
Postnatal death 6 11.43 3.3
Meconium stained liquor 48 --- 10
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TABLE COMPARING INCIDENCE OF ADVERSE OUTCOMES
AMONG BORDERLINE AND SEVERE OLIGOHYDRAMNIOS GROUPS
ADVERSE OUTCOMES SEVERE OLIGOHYDRAMNIOS BORDERLINE OLIGOHYDRAMNIOS
Meconium stained liquor 7.1 12.5
Preterm delivery 7.1 7.1
IUGR 50 37.5
LSCS for FD 50 25
NICU admission 28.5 43.75
Postnatal death --- 6.25
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DIAGNOSTIC STATISTICS- SENSITIVITY, SPECIFICITY,
PPV, NPV AND ACCURACY OF VARIOUS DOPPLER INDICES
IN PREDICTING ADVERSE OUTCOMES
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• There was higher incidence of adverse outcomes
  when the Doppler velocimetry of the uterine
  artery, umbilical artery and fetal MCA was
  abnormal. In these cases, there was a higher
  incidence of IUGR and NICU admission.
• The presence of diastolic notch had the highest
  specificity and positive predictive value (100)
  among the uterine artery indices, while RI and PI
  had good specificity (90)
• In the umbilical artery, RI, PI and S/D ratio had
  similar sensitivity, specificity, positive and
  negative predictive values of 45, 100, 100 and
  47.62 respectively.
• In the MCA, cerebro-placental ratio had the
  highest sensitivity, specificity, positive and
  negative predictive values of 35, 100, 100 and
  43.68 with an accuracy of 56.67.

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CONCLUSION

• Based on the results and the methodology
  employed, we have concluded from our study that
• AFI lt 5cm and AFI 5-8cm in third trimester of
  pregnancy are both associated with adverse
  outcomes in the intra-partum and post-partum
  period.
• Severe oligohydramnios has increased incidence of
  adverse outcomes than borderline oligohydramnios.
• Among the uterine artery Doppler indices,
  presence of diastolic notch has the highest
  specificity and positive predictive value.
• All three umbilical artery Doppler indices have
  similar sensitivity, specificity, positive and
  negative predictive values with good accuracy in
  identifying adverse outcomes.

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• Among the fetal MCA Doppler indices, the
  cerebro-placental ratio has the highest
  sensitivity, specificity, positive and negative
  predictive values with an accuracy of 56.67 in
  identifying adverse outcomes.
• Uterine artery, umbilical artery and fetal MCA
  Doppler velocimetry are all associated with
  increased incidence of adverse outcomes in both
  severe and borderline oligohydramnios. An
  abnormal study of all three vessels has the
  highest incidence of IUGR and NICU admission. We
  also found that adverse outcomes can still occur
  even if the Doppler of one vessel is abnormal and
  the other two are normal.
• Thus from our study, we conclude that for third
  trimester oligohydramnios, Doppler velocimetry of
  uterine, umbilical and fetal MCA together does
  serve as a good indicator of fetuses at risk of
  developing adverse outcomes for prompt
  management.

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