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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 5  |  Page : 552-556  

Diagnosis of fetal asphyxia depending on the change of blood flow of fetal middle cerebral artery and umbilical artery using color Doppler ultrasonography


Department of Obstetrics and Gynecology, Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic People's Republic of Korea

Date of Submission14-Mar-2019
Date of Decision25-Oct-2019
Date of Acceptance31-Dec-2019
Date of Web Publication7-Sep-2020

Correspondence Address:
Sung-Kuk Kim
Pyongyang Medical College, Kim Il Sung University, Pyongyang
Democratic People's Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_83_19

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  Abstract 


Introduction: Ultrasonography has been used in the medical field for more than 50 years and estimated to be safe. The aim of the study was to set the criteria for the diagnosis of fetal asphyxia depending on the indices of fetal middle cerebral artery (FMCA) and umbilical artery (UA). Subjects and Methods: Color Doppler ultrasound (ALOKA-SSD1700) was used to confirm the dynamics of blood flow indices in fetal arteries. Among 417 pregnant women (327 normal and 90 with fetal distress), various arterial velocimetric parameters (ratio of systole to diastole and pulsatility and resistance indexes) were evaluated in the FMCA and UA. t-test and Chi-square test were used for the comparison of average and ratios, respectively, and Ridit test for grading of data. Results: The normal values of blood flow indices of FMCA with gestational age in normal pregnancy reached their peak at the 30th week and then gradually decreased. As for funicular artery, the indices reached their peak at the 28th week and then gradually decreased. The criterion for the diagnosis of fetal asphyxia depending on the blood flow of FMCA and UA is the ratio of resistance indices in the MCA or UA =.10, and the sensitivity, specificity, and accuracy of diagnosis were 86.7%, 98.8%, and 96.2%, respectively.
Conclusion: The study confirmed the normal values and dynamics of the blood flow indices of FMCA and UA according to the number of weeks of normal pregnancy and determined criteria for the diagnosis of fetal asphyxia depending on those indices.

Keywords: Color Doppler ultrasound, fetal asphyxia, pregnancy, ratio of systole to diastole, middle cerebral artery, umbilical artery, pulsatility index, resistance index


How to cite this article:
Kim SK, Paek MY, Ko IK. Diagnosis of fetal asphyxia depending on the change of blood flow of fetal middle cerebral artery and umbilical artery using color Doppler ultrasonography. Med J DY Patil Vidyapeeth 2020;13:552-6

How to cite this URL:
Kim SK, Paek MY, Ko IK. Diagnosis of fetal asphyxia depending on the change of blood flow of fetal middle cerebral artery and umbilical artery using color Doppler ultrasonography. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Sep 30];13:552-6. Available from: http://www.mjdrdypv.org/text.asp?2020/13/5/552/294367




  Introduction Top


Recently, many methods to obtain biological information without any burden and damage to the mother and fetus have been reported in the department of obstetrics. In particular, ultrasonography has been used in the medical field for more than 50 years and estimated to be safe.[1],[2]

Thanks to the adoption of ultrasonography, obstetricians can diagnose not only fetal congenital heart malformation and fetal growth restriction but also estimate the fetal state through the analysis from velocimetry of umbilical artery (UA), uterine artery, fetal cerebral artery, and fetal aorta.[3],[4],[5],[6],[7],[8],[9]


  Subjects and Methods Top


Subjects

The study has obtained institutional approval from the local ethics committee, and only patients who provided the written informed consents for participation after detailed explanation were included in our study.

A total of 327 normal pregnancies between 28 and 40 gestational weeks without any complicating or intercurrent diseases of pregnancy and 90 pregnancies that had been diagnosed as fetal asphyxia by the Biophysical Profile Score (BPS) were included in the study [Table 1].
Table 1: Composition of groups

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  Methods Top


In order to confirm the dynamics of blood flow indices in fetal middle cerebral artery (FMCA) and UA with normal gestational age, a color Doppler ultrasound (ALOKA-1700, Teveik Technology Co, Shenzhen City, China) was used.

Ultrasonic measurements for different fetal parts were performed three times at their standard sections to calculate the means, which are described as follows:

  • As for FMCA, Willis circle was measured three times at the horizontal section of the fetal head to calculate the means. As for UA, the image that has more than five equal peaks was fixed and measured three times to calculate the means
  • Wave type of velocity for blood flow was analyzed using the following formulas:


Ratio of systole to diastole: R = S/D

Pulsatility index (PI) = (SD)/M

Resistance index (RI) = (SD)/S

(where S: Velocity at systole, D: Velocity at diastole, and M: Mean velocity)

In order to determine criteria for the diagnosis of fetal asphyxia depending on the change of the blood flow of FMCA and UA, ninety pregnancies who had been diagnosed as fetal asphyxia were studied to find the blood flow indices of FMCA – RMCA, PIMCA, and RIMCA and the blood flow indices of UA – ratio of systole to diastole (RUA), PlUA, and RIUA. The ratio of blood flow indices of FMCA and UA (RMCA/RUA, PIMCA/PIUA, and RIMCA/RIUA) was calculated.

Statistical analysis was performed using t-test for comparison of average, Chi-square test for comparison of ratios, and Ridit-test for grading of data using SPSS software (version 16.0, IBM Corp, New York, USA), and P < 0.05 was regarded as statistically significant.


  Results Top


  1. The study on normal values and dynamics of blood flow indices of FMCA with gestational age in pregnancy showed that they gradually decrease from 30 weeks after increasing with gestational age. As for UA, the indices reached their peak at 28 weeks and then gradually decreased [Figure 1], [Figure 2], [Figure 3]
  2. The criterion for the diagnosis of fetal asphyxia depending on the blood flow indices of FMCA and UA is the ratio of RIs (RMCA/RUA) =.10.
Figure 1: RMCAaccording to gestational weeks. Note that the RMCAreached the peak of 7.42 ± 0.21 at the 30th week and then gradually decreased to 3.57 ± 0.06 at the 40th week. RMCA: Ratio of systole to diastole of the middle cerebral artery

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Figure 2: PIMCAaccording to gestational weeks. Note the ratio of (PIMCAof blood flow of fetal middle cerebral artery reached the peak of 1.50 ± 0.02 at the 30th week and then gradually decreased to 1.13 ± 0.02 at the 40th week. PIMCA: Pulsatility index of middle cerebral artery

Click here to view
Figure 3: Pulsatility index middle cerebral artery according to gestational weeks. Note that (RIMCA) of blood flow of fetal middle cerebral artery reached the peak of 0.85 ± 0.01 at the 30th week and then gradually decreased to 0.73 ± 0.01 at the 40th week. RIMCA: Resistance index of middle cerebral artery

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The number of cases with high RUA of blood flow of UA was statistically significantly (P < 0.001) higher in gravidas with fetal asphyxia than that in normal ones [Table 2].
Table 2: Comparison of ratio of systole to diastole of middle cerebral artery/ratio of systole to diastole umbilical artery of normal pregnancy and those with fetal asphyxia

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The number of cases with high PI (PIMCA/PIUA) of blood flow of UA was statistically significantly (P < 0.001) higher in gravidas with fetal asphyxia than that in normal ones [Table 3].
Table 3: Comparison of pulsatility index of middle cerebral artery/pulsatility index of umbilical artery of normal pregnancy and those with fetal asphyxia

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The number of cases with low ratio of RI (RIMCA/RIUA) of blood flow of FMCA and funicular artery was statistically significantly (P < 0.001) higher in gravidas with fetal asphyxia than that in normal ones [Table 4].
Table 4: Comparison of resistance index middle cerebral artery/resistance index umbilical artery of normal pregnancy and those with fetal asphyxia

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All the blood flow indices of FMCA and UA of the normal and fetal asphyxia were brought together and comparatively analyzed [Table 5]. When the standard ratio of RIs of blood flow of FMCA and UA was set to 1.10, the accuracy of diagnosis was the highest at 96.2%.
Table 5: Diagnostic value of ultrasonic blood flow indices in diagnosing fetal asphyxia and their specificities, sensitivities and accuracies

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  Discussion Top


Pregnancy care during perinatal period is very important in reducing the morbidity of pregnancy due to pregnancy and labor and the mortality of fetus and newborn. Especially, prevention and adequate care for fetal asphyxia is of great importance.

Now, fetal asphyxia is diagnosed by BPS. However, due to lengthy time and an insufficient accuracy, this method is not widely used. As velocimetry can be estimated with Doppler sonography in the obstetrical field, it is considered an important test with high diagnosable level and estimation of fetal circulation.[10],[11]

Doppler sonography involves two methods: continuous and impulse Doppler.[2],[7] Continuous Doppler adopted in velocimetry firstly in 1961 has the advantage of high velocimetry, but its disadvantage includes an inability to check local velocimetry with getting all-regional Doppler signals in the ultra-scan field.[5],[12]

In the early days, Doppler sonography usage was limited mainly to superficial blood vessels' velocimetry by continuous ones, but as the distance analyzable pulse-Doppler has been developed in the recent decade, it gets high-diagnosable and mostly adoptable power.[12]

Doppler sonography involves two methods: Color ones to be colorized by blood direction, power ones to be colorized by color intensity, and pulse ones to indicate blood velocimetry as pulse.[12]

Because color Doppler displays red if the direction of blood goes toward the probe and blue if it goes away from the probe, existence and its direction of blood vessels can be identified.[13]

Power Doppler cannot find the blood direction as it does not display the color by its velocimetry.[10],[12]

Velocimetry of UA and FMCA is easily done and has high correction by pulse Doppler.[5],[14]

Research has been conducted to evaluate the diagnostic criteria of fetal distress with the standard and variation of gestational FMCA and UA veloci-indices in normal pregnancy. Thus, we have established a diagnostic method for fetal asphyxia depending on the dynamics of the blood flow of FMCA and funicular artery using color Doppler ultrasound.


  Conclusion Top


  1. The normal values of the blood flow indices of FMCA with gestational age in normal pregnancy reached their peak at the 30th week and then gradually decreased. As for funicular artery, the indices reached their peak at the 28th week and then gradually decreased
  2. The criterion for the diagnosis of fetal asphyxia depending on the blood flow of FMCA and UA is the ratio of RI (RIMCA/RIUA) =.10, and the sensitivity, specificity, and accuracy of diagnosis were 86.7%, 98.8%, and 96.2%, respectively.


Acknowledgment

We are thankful to all the patients for their participation in this study. We appreciate Dr. Cho Song-Jun for his kind advice in preparing manuscripts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Phillips RA, Stratmeyer ME, Harris GR. Safety and U.S. Regulatory considerations in the nonclinical use of medical ultrasound devices. Ultrasound Med Biol 2010;36:1224-8.  Back to cited text no. 1
    
2.
Thomas S. Basic Principles and Safety of Diagnostic Ultrasound in Obstetrics and Gynecology; 2011.  Back to cited text no. 2
    
3.
Kutz AM, Aranibar L, Lobos N, Wortsman X. Color Doppler ultrasound follow-up of infantile hemangiomas and peripheral vascularity in patients treated with propranolol. Pediatr Dermatol 2015;32:468-75.  Back to cited text no. 3
    
4.
Vollgraff Heidweiller-Schreurs CA, De Boer MA, Heymans MW, Schoonmade LJ, Bossuyt PM, Mol BW, et al. Prognostic accuracy of cerebroplacental ratio and middle cerebral artery Doppler for adverse perinatal outcome: Systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018;51:313-22.  Back to cited text no. 4
    
5.
Komacki J, Skrzypczak J. The use of Doppler in the second half of pregnancy. Ginekol Pol 2015;86:626-30.  Back to cited text no. 5
    
6.
Schenone MH, Mari G. The MCA Doppler and its role in the evaluation of fetal anemia and fetal growth restriction. Clin Perinatol 2011;38:83-102, vi.  Back to cited text no. 6
    
7.
Su YM, Lv GR, Chen XK, Li SH, Lin HT. Ultrasound probe pressure but not maternal Valsalva maneuver alters Doppler parameters during fetal middle cerebral artery Doppler ultrasonography. Prenat Diagn 2010;30:1192-7.  Back to cited text no. 7
    
8.
Prior T, Wild M, Mullins E, Bennett P, Kumar S. Sex specific differences in fetal middle cerebral artery and umbilical venous Doppler. PLoS One 2013;8:e56933.  Back to cited text no. 8
    
9.
Warren M. Principles of Doppler Echocardiograph; 2012.  Back to cited text no. 9
    
10.
Cancarevic Djajic B, Vilendecic R, Ecim-Zlojutro V, Lucic N, Draganovic D, Savic S. Hemodynamics of arterial and venous circulation in the intrauterine fetal evaluation. Acta Inform Med 2012;20:249-53.  Back to cited text no. 10
    
11.
Naila K, Aneela U, Sadia K. Umbilical artery Doppler Velocimetry: A valuable tool for antenatal fetal surveillance. Annals 2013;19:216-25.  Back to cited text no. 11
    
12.
Arbeille P, Caries G, Tobal N, Herault S, Georgescus M, Bousquet F, et al. Fetal flow redistribution to the brain in response to malaria infection: Does protection of the fetus against malaria develop over time? J Ultrasound Med 2002;21:739-46.  Back to cited text no. 12
    
13.
Maulik D. Doppler Ultrasound of the Umbilical Artery for Fetal Surveillance; 2012.  Back to cited text no. 13
    
14.
Bellussi F, Perolo A, Ghi T, Youssef A, Pilu G, Simonazzi G. Diagnosis of severe fetomaternal hemorrhage with fetal cerebral Doppler: Case series and systematic review. Fetal Diagn Ther 2017;41:1-7.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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