DOPPLER ULTRASOUND

in Pregnancy

Dr. Mohammed Abdalla

Egypt, Domiat Hospital
 Doppler History

First use of Doppler

ultrasonography to study
flow velocity in the fetal
umbilical artery
was reported in 1977
 Doppler History
Fitzgerald & Drumm. Umbilical artery studies 1977BMJ
Eik-Nes et al. Fetal aortic velocimetry : Dupplexscanner
1980 Lancet
Campbell et al. Utero-placental circulation: Dupplex
scanner 1983 Lancet
Wladimiroff et al. MCA / UA PI ratio 1987 OG
Kiserud et al. Ductus venosus velocimetry 1991Lancet
 Basic principals
Echoes from stationary tissues are the same from
pulse to pulse.
Echoes from moving objects exhibit slight
differences in the time for the signal to be
returned to the receiver.

These differences can measured as phase shift from which the Doppler frequency is obtained.

.
T1 : time of omitted signal .
T2 : time of returned signal .

T2 – T1 = time difference or phase

shift .

from phase shift the Doppler frequency

is obtained.

AS TIME DIFFERENCE DECREASE THE

DOPPLER FREQUENCY INCREASE.
 T2

T1
pulse repetition frequency

(T2 –T1) phase shift with known beam / flow angle can
calculate flow velocity .
 Basic Principals

The time difference or phase shift

are then proceeded to produce
either colorflow display or a
Doppler sonogram
 Basic Principals
 ‘Doppler frequency’ is obtained by measuring
the time difference for the signal to be returned
when reflected from moving scatterers .
 Doppler frequency increase if:
1. flow velocity increased .
2. beam is more aligned to the direction of
flow.
3. higher transducer frequency is used.
Factors affecting doppler frequency 3
Fr
eq
.

2
The angle of insonation
q
Flow velocity 1

(the angle q between the beam and the direction of

flow becomes smaller). This is of the utmost
importance in the use of Doppler ultrasound.
(the angle q between the beam and the direction of flow
becomes smaller). This is of the utmost importance in the
use of Doppler ultrasound.

beam (A) is more aligned than (B)

The beam/flow angle at (C) is almost 90° and there is a very poor Doppler signal

The flow at (D) is away from the beam and there is a negative signal.
 Aliasing

If a second pulse is sent before the first is received, the receiver cannot
discriminate between the reflected signal from both pulses and aliasing
occur.
 Aliasing

So to eliminate aliasing The

pulse repetition frequency or
scale is set appropriately for
the flow velocities
 Basic Principals
The volume flow in the UAs increases
with advancing gestation. The high
vascular impedance detected in the
first trimester gradually decreases.
It is attributed to growth of placental
unit and increase in the number of
the functioning vascular channels.
 Uses
plays a vital role in the diagnosis of
fetal cardiac defects .
assessment of the hemodynamic
responses to fetal hypoxia and
anemia.
diagnosis of other non-cardiac
malformations.
 Anatomy
Anatomy
Blood
Blood supply
supply provided
provided byby
the
the ovarian
ovarian and
and uterine
uterine
arteries
arteries
Uterine
Uterine Arteries:
Arteries: main
main
branches
branches of of the
the internal
internal
iliac
iliac arteries
arteries
Uterine
Uterine Arteries:
Arteries: Ascend
Ascend
through
through the
the lateral
lateral wall
wall and
and
anastomose
anastomose with with the
the
ovarian
ovarian arteries
arteries
 Anatomy
Anatomy
 Arcuate
Arcuate Arteries:
Arteries: Run
Run Circumferentially
Circumferentially around
around the
the uterus
uterus
 Uterus:
Uterus: Blood
Blood supply
supply to
to anterior
anterior and
and posterior
posterior walls
walls
provided
provided by
by the
the Arcuate
Arcuate arteries
arteries
 Radial
Radial Arteries:
Arteries: Extend
Extend from
from the
the arcuate
arcuate arteries
arteries and
and
enter
enter the
the endometrium
endometrium
 Spiral
Spiral Arteries:
Arteries: connect
connect the
the maternal
maternal circulation
circulation to
to the
the
endometrium
endometrium

 Responsible
Responsible for
for aa 10
10 fold
fold increase
increase in
in blood
blood flow
flow
 Anatomy
Anatomy

Conversion of small muscular spiral arteries into large

vascular channels transforms the uteroplacental
circulation into a low-resistance-to-flow system. These
have a dilated and tortuous lumen, a complete absence
of muscular and elastic tissue, no continuous
endothelial lining.
Umbilical artery
doppler
Doppler indices
 Umbilical artery

UMBILICAL ARTERY FLOW

characteristic saw-tooth appearance of arterial
flow in one direction and continuous umbilical
venous blood flow in the other.
FACTORS AFFECTING UMBILICAL ARTERY DOPPLER
*FLOW VELOCITY WAVEFORMS
 Umbilical artery

Benefit of Umbilical Artery Evaluation

Less experienced operators can achieve
highly reproducible results with simple,
inexpensive continuous-wave
equipment .
 Umbilical artery

The 40% of the combined fetal ventricular output is directed to the placenta by two umbilical arteries. The assessment of umbilical blood flow provides
information on blood perfusion of the fetoplacental unit .

.
 Umbilical artery

With advancing gestation,

umbilical arterial Doppler
waveforms demonstrate a
progressive rise in the
end-diastolic velocity and
a decrease in the
pulsatility index.
Middle cerebral artery
doppler
The possible Doppler velocimetry sites
Middle cerebral artery

Using color flow imaging, the middle cerebral artery can be

seen as a major lateral branch of the circle of Willis, running
anterolaterally at the borderline between the anterior and the
middle cerebral fossae
 Middle cerebral artery

The blood velocity increases with advancing gestation,

and this increase is significantly associated with the
decrease in PI
 Middle cerebral artery

An early stage in fetal adaptation   to  hypoxemia -

central redistribution of blood flow
   ( brain-sparing reflex) 
increased blood flow to protect the brain, heart,
and adrenals
reduced flow to the peripheral and placental
circulations
     
 
 
Doppler wave form of early stage of
     fetal hypoxemia

increased end-diastolic flow in the middle

cerebral artery (lower MCA pulsatility
index or resistance index)

 Average of both MCAs must be calculated

for more precise result
 Middle Cerebral Artery

Flow velocity waveform in the fetal middle cerebral artery

in a severely anemic fetus at 22 weeks (left) and in a
normal fetus (right). In fetal anemia, blood velocity is
increased
 Middle Cerebral Artery

When the fetus is hypoxic, the cerebra arteries

tend to become dilated in order to preserve
the blood flow to the brain and The systolic to
diastolic (A/B) ratio will decrease (due to an
increase in diastolic flow)
 Doppler ultrasound for the fetal assessment in
high-risk pregnancies
(Cochrane Review). In: The Cochrane Library,
1999. Neilson JP and Alfirevic Z

11 Studies Included In Analysis

 Trudinger et al 1987 Almstrom et al 1992
 McParland et al 1988 Biljan et al 1992
 Tyrrell et al 1990 Johnstone et al 1993
 Hofmeyr et al 1991 Pattison et al 1994
 Newham et al 1991 Nienhuis et al 1997
 Burke et al 1992
Doppler ultrasound for the fetal assessment
in high-risk pregnancies

Meta analysis
Nearly 7000 patients were included

The trials compared no Doppler ultrasound to

Doppler ultrasound in high-risk pregnancy
(hypertension or presumed impaired fetal
growth)
Doppler ultrasound for the fetal assessment
in high-risk pregnancies
Main results
 A reduction in perinatal deaths.
 Fewer inductions of labour .
 Fewer admissions to hospital .
 no report of adverse effects .
 No difference was found for fetal distress
in labour .
 No difference in caesarean delivery .
 Biophysical profile for fetal assessment in
high risk pregnancies

• When compared with conventional fetal monitoring

(usually cardiotocography) biophysical profile
testing showed no obvious effect (either beneficial
or deleterious) on pregnancy outcome. There was
an increase in the number of inductions of labour
following biophysical profile in the trial.

Alfirevic Z, Neilson JP. Biophysical profile for fetal assessment in high risk
pregnancies (CochraneReview). In: The Cochrane Library, 1995.