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Blinded comparison of doppler velocimetry and modified biophysical profile in the IUGR fetus
S152
SPO Abstracts
J a n u a r y 1997 A n r J Obstet Gynecol
527
DOPPLER ASSESSMENT OF THE SPLENIC ARTERY BLOOD FLOW VELOCITY WAVEFORMS IN THE ANEMIC FETUS BEFORE AND AFTER INTRAVASCULAR TRANSFUSION. R. Levi D'Ancona, x ~2 Rahman, ~ R. Bahado-Singh, f Copel, G. Marl. Depts Ob/Gyn, Yale University School of Medicine, New Haven, CT, and King Faisal Specialist Hospital, Riyadh (Saudi Arabia) OBJECTIVE: To assess flow velocity"waveform of the splenic artery (SA) of the anemic fetus prior to and following intrauterine transthsion. STUDY DESIGN: Color guided pulsed Doppler was used to obtain the resistance index (RI) and the peak velocity (PV) from the SA in I0 anemic fetuses that were transfused in utero for Rh-alloiinmunization. A paired t-test was used for the statistical analysis. A p < 0.05 was considered statistically significant. RESULTS: Twelve intrauterine transfusions were performed; gestational age ranged from 20 to 34 weeks (mean + SD: 26 + 4.42 weeks). The hematocrit ranged from 5.9% to 31.2% (mean m SD: 21.9% -+ 8.2%) prior to transfusion; whereas, it was between 30.2% and 51.9% (mean -+ SD: 45.2% _+ 7.9%) after transfusion. The splenic artery RI (mean -+ SD) was 0.78 + 0.064 prior to transfusion; it was 0.64 + 0.096 after transfusion (p < 0.05). The PV of the splenic artery was 48.5 _+ 17.5 cm/s before transfusion, and it was 50.12 _+ 29.4 cm/s tbllowing transfusion (p > 0.05). CONCLUSIONS: 1) The decrease in splenic artery RI after transfusion suggests an increased blood flow to the spleen; 2) the lack of a change of the peak velocity of the splenic artery following transfusion suggests that it is not a good indicator of fetal anemia, as has been reported with the middle cerebral artery peak velocity. Further studies are necessary.
529
BLINDED COMPARISON OF DOPPLER VELOCIMETRY AND MODIFIED BIOPHYSICAL PROFILE IN THE IUGR FETUS. F. Gallousis~ t{ Bonebrake, T. Asrat, C. Towers, M. Nageotte. Dept. Ob/Gyn, Long Beach Memorial Medical Center, Long Beach, CA. UC hwine Medical Center, Orange, CA. OBJECTIVE: To compare, in a blinded fashion, the ability of umbilical artery Doppler to that of the modified biophysical profile (MBPP-2X weekly NST+AFI) to predict adverse outcomes in a known 1UGR fetus with birtfiweight <3rd percentile. STUDY DESIGN: Umbilical artery Doppler data were collected at the time of antepartum fetal heart rate testing. The Doppler results were blinded and categorically not used in the clinical management of patients. Inclusion criteria consisted of those tested for a clinical suspicion of [UGR, had a MBPP and umbilical artery Doppler study as their last test, and a birthweight <3rd %lie. Adverse outcome was defined as admission to the NICU (for reasons other than birthweight), meconium passage, 5 minute Apgar <7, antenatal cesarean section, cesarean section for fetal distress within the first two hours of labor, mnbilical artery pH <7.2, antepartmn, or neonatal death. RESULTS: 53 patients were evaluated with birthweights <3rd %ile. There were no antepartum or neonatal deaths. The overall sensitivity and PPV of Doppler analysis to predict a fetus with any adverse outcome was 36 and 41%, respectively; and that of the MBPP was 44 and 50%, respectively. Combining the two modalities increased the sensitivity to 71%; however, decreased the PPV to 41%. There were no differences in outcome between those with normal and abnormal Doppler results when both groups had a normal MBPP. Fetuses in the group with both abnormal tests had higher incidences of cesarean section for fetal distress, lower mnbilical artery pH's, and greater chances of having an adverse outcome. When the MBPP was abnormal, the gestational age at delivery was earlier (38.1--3.3 vs 35.+2.6 wks) with an increase in adverse outconms in the group with abnormal Doppler. CONCLUSIONS: Within a strictly defined cohort of growth restricted fetuses (<3rd %ile), umbilical artery Doppler velocimen'y does not appear to offer any improvement in detecting the fetus at risk for an adverse outcome when there is a normal MBPP. Furthermore, the use of Doppler in combination with the MBPP may decrease the PPV; thereby, increasing the risk of unnecessary intervention and iatragenic prematurity.
528
THE EFFECT OF INTRAVASCULAR BLOOD TRANSFUSION O N THE FLOW VELOCITY WAVEFORM OF THE HEPATIC VENOUS SYSTEM OF THE ANEMIC FETUS. R. Levi D'Ancona, x I~ Rahman, X[ Copel, G. Maff. Depts Ob/Gyn, Yale University School of Medicine, New Haven, CT, and King Faisa] Specialist Hospital, Riyadh (Saudi Arabia) OBJECTIVE: To assess flow velocity waveforms of the hepatic venous system of the anemic fetus prior to and within two hours following intrauterine transfusion. STUDY DESIGN: Color guided pulsed Doppler was used to obtain flow velocity waveforms from the fetal portal vein (PV) in 15 anemic fetuses that were transfused in utero for Rh-alloimmunization. The PV velocity pattern was defined as continuous when no change in velocity during the cardiac cycle was noted. It was defined as pulsatile when a deflection of the wave was present. The flow velocity waveforms were quantified by using the ratio between the highest (H) and the lowest (L) velocities ( H / L ratio). RESULTS: Eighteen intrauterine transihsions were performed. Gestational age ranged from 19.5 to 35 weeks (mean + SD: 26.3 + 5.9 weeks). The hematocrit ranged from 5.9% to 40% (mean + SD: 21.6% _+ 9.3%) prior to transfusion; whereas, it was between 24.8% and 56.7% (mean -+ SD:44.3% + 9.6%) after transfusion. In 50% of the cases the waveibrms were pulsatile before transfusion; in the other 50% they were continuous. The pulsatile pattern was present tollowing transfusion in 89% of the cases (Fisher's exact test; p<0.05). The H / L ratio was 1.37 • 0.32 prior to transfusion and 2.01 + 0.96 after transfusion (t-test; p < 0.05). CONCLUSIONS: 1) Because the portal vein has continuous nonpulsatile flow in the normal fetus, the presence of pulsatility in the waves of 50% of the anemic fetuses may suggest portal hypertension; 2) the H / L ratio following transfusion suggests a disproportion between the volume of blood flowing tbrough the portal system and the portal vascular compliance.
530
DOPPLER ASSESSMENT OF THE EFFECT OF UMBILICA~CORD LIGATION OF ACARDIAC TWINS; [L. Martfnez Pooo~erx, RA. Qaintero, CA. Carre~ox, 34. King', SF. Bottoms, R. Romero, ML Evans. Department of Obstetrics and Gynecology, Wayne State University, Detroit, ML OBJECTIVE: We have proposed fetoscopic umbilical-cord ligation (UCL) as a management alternative for acardiac twins. We wished to study the hemodynamic effects of this technique on the smwiving twin. STUDY DESIGN: Pulsed Doppler of the umbilical artery, middle cerebral artery and thoracic aorta was performed on the pump twin before and after UCL. Standard arterial Doppler parameters were calculated. The ductus venosus (DV), right hepatic vein, the inferior vena cava (IVC) and the umbilical vein were also assessed. The systolic and diastolic peak velocities of these vessels were calculated. The peak velocity of the atrial contraction waveform (ACPV), the velocity-time integral of forward flow of the IVC (VTIIVC) and of the atrial contraction waveform (VTIAC) were also calculated. The IVC pre-load index was calculated as ACPV/peak velocity during systole. Three consecutive uniform waveforms in the absence of fetal breathing, arrhythmia or movement were measured and averaged. Each case served as its own control. Post-operative assessment was performed within 1.2 days of the procedure. Information was considered complete if pre-and post-operative data was available. Differences were analyzed with paired Student's T-test. RESULTS: Ten patients underwent UCL, but complete data was only available in 5. Four of 5 studied fetuses sm'vived. There were no significant post-operative differences in the Doppler parameters of the arterial vessels. However, subjective changes were apparent, with easy detection of peripheral arteries (tibial, radial, pedial). A significant post-operative decrease of the ACPV and the VTIAC was noted (p<0.01). A mean reduction of 33.2% in the preload index of the IVC was observed (range 13%-51%), (p-0.009). CONCLUSIONS: UCL is not associated with increased impedance to blood flow in the smMving twin. Subjective arterial findings may indicate post-operative redistribution of blood, with a net zero effect on standard arterial Doppler parameters. Doppler assessment of the venous system shows clear post-operative changes. Pulsed Doppler interrogation of the 1VC lnay have diagnostic valne to estimate the excess volume originally handled by the pump twin. Clinical and Doppler data suggest that UCL is well tolerated by the smMving fetus.
SPO Abstracts
J a n u a r y 1997 A n r J Obstet Gynecol
527
DOPPLER ASSESSMENT OF THE SPLENIC ARTERY BLOOD FLOW VELOCITY WAVEFORMS IN THE ANEMIC FETUS BEFORE AND AFTER INTRAVASCULAR TRANSFUSION. R. Levi D'Ancona, x ~2 Rahman, ~ R. Bahado-Singh, f Copel, G. Marl. Depts Ob/Gyn, Yale University School of Medicine, New Haven, CT, and King Faisal Specialist Hospital, Riyadh (Saudi Arabia) OBJECTIVE: To assess flow velocity"waveform of the splenic artery (SA) of the anemic fetus prior to and following intrauterine transthsion. STUDY DESIGN: Color guided pulsed Doppler was used to obtain the resistance index (RI) and the peak velocity (PV) from the SA in I0 anemic fetuses that were transfused in utero for Rh-alloiinmunization. A paired t-test was used for the statistical analysis. A p < 0.05 was considered statistically significant. RESULTS: Twelve intrauterine transfusions were performed; gestational age ranged from 20 to 34 weeks (mean + SD: 26 + 4.42 weeks). The hematocrit ranged from 5.9% to 31.2% (mean m SD: 21.9% -+ 8.2%) prior to transfusion; whereas, it was between 30.2% and 51.9% (mean -+ SD: 45.2% _+ 7.9%) after transfusion. The splenic artery RI (mean -+ SD) was 0.78 + 0.064 prior to transfusion; it was 0.64 + 0.096 after transfusion (p < 0.05). The PV of the splenic artery was 48.5 _+ 17.5 cm/s before transfusion, and it was 50.12 _+ 29.4 cm/s tbllowing transfusion (p > 0.05). CONCLUSIONS: 1) The decrease in splenic artery RI after transfusion suggests an increased blood flow to the spleen; 2) the lack of a change of the peak velocity of the splenic artery following transfusion suggests that it is not a good indicator of fetal anemia, as has been reported with the middle cerebral artery peak velocity. Further studies are necessary.
529
BLINDED COMPARISON OF DOPPLER VELOCIMETRY AND MODIFIED BIOPHYSICAL PROFILE IN THE IUGR FETUS. F. Gallousis~ t{ Bonebrake, T. Asrat, C. Towers, M. Nageotte. Dept. Ob/Gyn, Long Beach Memorial Medical Center, Long Beach, CA. UC hwine Medical Center, Orange, CA. OBJECTIVE: To compare, in a blinded fashion, the ability of umbilical artery Doppler to that of the modified biophysical profile (MBPP-2X weekly NST+AFI) to predict adverse outcomes in a known 1UGR fetus with birtfiweight <3rd percentile. STUDY DESIGN: Umbilical artery Doppler data were collected at the time of antepartum fetal heart rate testing. The Doppler results were blinded and categorically not used in the clinical management of patients. Inclusion criteria consisted of those tested for a clinical suspicion of [UGR, had a MBPP and umbilical artery Doppler study as their last test, and a birthweight <3rd %lie. Adverse outcome was defined as admission to the NICU (for reasons other than birthweight), meconium passage, 5 minute Apgar <7, antenatal cesarean section, cesarean section for fetal distress within the first two hours of labor, mnbilical artery pH <7.2, antepartmn, or neonatal death. RESULTS: 53 patients were evaluated with birthweights <3rd %ile. There were no antepartum or neonatal deaths. The overall sensitivity and PPV of Doppler analysis to predict a fetus with any adverse outcome was 36 and 41%, respectively; and that of the MBPP was 44 and 50%, respectively. Combining the two modalities increased the sensitivity to 71%; however, decreased the PPV to 41%. There were no differences in outcome between those with normal and abnormal Doppler results when both groups had a normal MBPP. Fetuses in the group with both abnormal tests had higher incidences of cesarean section for fetal distress, lower mnbilical artery pH's, and greater chances of having an adverse outcome. When the MBPP was abnormal, the gestational age at delivery was earlier (38.1--3.3 vs 35.+2.6 wks) with an increase in adverse outconms in the group with abnormal Doppler. CONCLUSIONS: Within a strictly defined cohort of growth restricted fetuses (<3rd %ile), umbilical artery Doppler velocimen'y does not appear to offer any improvement in detecting the fetus at risk for an adverse outcome when there is a normal MBPP. Furthermore, the use of Doppler in combination with the MBPP may decrease the PPV; thereby, increasing the risk of unnecessary intervention and iatragenic prematurity.
528
THE EFFECT OF INTRAVASCULAR BLOOD TRANSFUSION O N THE FLOW VELOCITY WAVEFORM OF THE HEPATIC VENOUS SYSTEM OF THE ANEMIC FETUS. R. Levi D'Ancona, x I~ Rahman, X[ Copel, G. Maff. Depts Ob/Gyn, Yale University School of Medicine, New Haven, CT, and King Faisa] Specialist Hospital, Riyadh (Saudi Arabia) OBJECTIVE: To assess flow velocity waveforms of the hepatic venous system of the anemic fetus prior to and within two hours following intrauterine transfusion. STUDY DESIGN: Color guided pulsed Doppler was used to obtain flow velocity waveforms from the fetal portal vein (PV) in 15 anemic fetuses that were transfused in utero for Rh-alloimmunization. The PV velocity pattern was defined as continuous when no change in velocity during the cardiac cycle was noted. It was defined as pulsatile when a deflection of the wave was present. The flow velocity waveforms were quantified by using the ratio between the highest (H) and the lowest (L) velocities ( H / L ratio). RESULTS: Eighteen intrauterine transihsions were performed. Gestational age ranged from 19.5 to 35 weeks (mean + SD: 26.3 + 5.9 weeks). The hematocrit ranged from 5.9% to 40% (mean + SD: 21.6% _+ 9.3%) prior to transfusion; whereas, it was between 24.8% and 56.7% (mean -+ SD:44.3% + 9.6%) after transfusion. In 50% of the cases the waveibrms were pulsatile before transfusion; in the other 50% they were continuous. The pulsatile pattern was present tollowing transfusion in 89% of the cases (Fisher's exact test; p<0.05). The H / L ratio was 1.37 • 0.32 prior to transfusion and 2.01 + 0.96 after transfusion (t-test; p < 0.05). CONCLUSIONS: 1) Because the portal vein has continuous nonpulsatile flow in the normal fetus, the presence of pulsatility in the waves of 50% of the anemic fetuses may suggest portal hypertension; 2) the H / L ratio following transfusion suggests a disproportion between the volume of blood flowing tbrough the portal system and the portal vascular compliance.
530
DOPPLER ASSESSMENT OF THE EFFECT OF UMBILICA~CORD LIGATION OF ACARDIAC TWINS; [L. Martfnez Pooo~erx, RA. Qaintero, CA. Carre~ox, 34. King', SF. Bottoms, R. Romero, ML Evans. Department of Obstetrics and Gynecology, Wayne State University, Detroit, ML OBJECTIVE: We have proposed fetoscopic umbilical-cord ligation (UCL) as a management alternative for acardiac twins. We wished to study the hemodynamic effects of this technique on the smwiving twin. STUDY DESIGN: Pulsed Doppler of the umbilical artery, middle cerebral artery and thoracic aorta was performed on the pump twin before and after UCL. Standard arterial Doppler parameters were calculated. The ductus venosus (DV), right hepatic vein, the inferior vena cava (IVC) and the umbilical vein were also assessed. The systolic and diastolic peak velocities of these vessels were calculated. The peak velocity of the atrial contraction waveform (ACPV), the velocity-time integral of forward flow of the IVC (VTIIVC) and of the atrial contraction waveform (VTIAC) were also calculated. The IVC pre-load index was calculated as ACPV/peak velocity during systole. Three consecutive uniform waveforms in the absence of fetal breathing, arrhythmia or movement were measured and averaged. Each case served as its own control. Post-operative assessment was performed within 1.2 days of the procedure. Information was considered complete if pre-and post-operative data was available. Differences were analyzed with paired Student's T-test. RESULTS: Ten patients underwent UCL, but complete data was only available in 5. Four of 5 studied fetuses sm'vived. There were no significant post-operative differences in the Doppler parameters of the arterial vessels. However, subjective changes were apparent, with easy detection of peripheral arteries (tibial, radial, pedial). A significant post-operative decrease of the ACPV and the VTIAC was noted (p<0.01). A mean reduction of 33.2% in the preload index of the IVC was observed (range 13%-51%), (p-0.009). CONCLUSIONS: UCL is not associated with increased impedance to blood flow in the smMving twin. Subjective arterial findings may indicate post-operative redistribution of blood, with a net zero effect on standard arterial Doppler parameters. Doppler assessment of the venous system shows clear post-operative changes. Pulsed Doppler interrogation of the 1VC lnay have diagnostic valne to estimate the excess volume originally handled by the pump twin. Clinical and Doppler data suggest that UCL is well tolerated by the smMving fetus.