New insights in_pih_pune_new
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NEW IN PIH
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DR SAMEER DIKSHITMD.DGO.FCPS.FICOG
Hon Sonologist, Nowrosjee Wadia Maternity Home,Parel,Mumbai
Hon Fetal Medicine Consultant, BSES MG Hospital, Andheri,Mumbai
Irla Nursing Home,Irla,Mumbai
Sanket Sonography, Borivali, Mumbai
Boisar Fetal Medicine Consultant,Boisar
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• Pathophysiology of PIH
• Use of Doppler in PIH
• Evolution of Doppler changes
• “Point of action”
• Arterial v/s Venous Dopplers
• Special conditions
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Pathophysiology of PIH
• It’s a disorder of placental function
• Syndrome of endothelial dysfunction with associated vasospasm
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Placental Circulation
• Spiral Arterioles Placental Lake Uterine Vein
• Umbilical Arteries Placental Lake Umbilical Vein
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Placental Circulation
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Application of Doppler in PIH
• (1) Prediction of PIH
• (2) Monitoring the fetus
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Vessels studied
Arteries
• Uterine Artery
• Umbilical Artery
• Middle Cerebral Artery
• Thoracic Aorta
• Renal Artery
Veins
• Umbilical Vein
• Ductus Venosus
• IVC
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Monitoring of the Fetus
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Doppler Parameters
Umbilical Artery S/D > 3Absent End Diastolic Velocity
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MCAS/D > 4
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Why should increased spiral arteriole resistance lead to increased UA
resistance???• PIH is Maternal
Vasculitis
• There is no direct connection between Spiral Arteriole & UA
• Spiral A Venous lake circulates Uterine Vein
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The answer lies in the anatomy of placental villi
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Placental Circulation
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• Tertiary villi float in the venous lake
• Exchange of gases takes place
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Placental circulation in case of normal spiral vessels
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Increased resistance of the spiral arterioles
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Effect of stenosis of spiral arterioles
Normal-Lamellar flow
Effects of Stenosis
Increased Velocity
Turbulent flow and dampened velocity
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The circulation in placental lakes becomes sluggish
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This affects the gas exchange at the level of tertiary Villus
• Sluggish spiral arterioles to placental circulation
• Trans-Villus gas exchange is affected
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The Fetal vascular
adjustments overcome this
situation
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Decision to deliver......
• Primi
• 35 weeks A
• BP 140/90
• Came for routine check up
• On enquiry…..slightly reduced movements
• Umb Artery S/D 3.4 ?
• MCA S/D 3.6 ?
• USG-AFI=8.3
• Non reactive NST
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Umbilical Artery Doppler Indices in Small for Gestational age fetuses
J Ultrasound Med 2009
• When UA S/D & UA PI are adjusted for gestational age, their prediction of risk of complications is insignificant
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Comparison of NST with the evaluation of centralisation of blood flow for prediction
of neonatal compromise
Journal of Ultrasound in Obstetrics and Gynaecology 1999;14; 38-41
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Perinatal Morbidity
Reactive NST + Normal Doppler
11.3%
Reactive NST + Abnormal Doppler
37.5%
Non reactive NST + Normal Doppler
52.4%
Non reactive NST + Abnormal Doppler
60%
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Odds ratio
Non reactive NST
Abnormal Doppler
Significant neonatal complications
5.71 3.44
LSCS for fetal distress 4.73 2.84
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International Society of Ultrasound in Obstetrics and Gynaecology
Workshop on Second and Third Trimester Doppler
4-7 October,2001, Zagreb, Croatia
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• Normal UA S/D ratio
• Abnormal UA S/D ratio
• Absent Diastolic flow
• Reversed Diastolic flow
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• Normal UA S/D ratio - 0% perinatal mortality
• Abnormal UA S/D ratio- 7%perinatal mortality
• Absent Diastolic flow- 10% perinatal mortality
• Reversed Diastolic flow- 27% perinatal mortality
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Use of Doppler for “point of action”
• Abnormal indices can not be taken as indicators for “point of action” i.e. early delivery
• At the most, they indicate an ongoing process
• Indicate that, the fetus is at risk of complications
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IN PIH…
• Same information can be obtained by
– Clinical Examination (BP, Edema)
– Urine Albumin
– Gross USG features (IUGR, Oligohydramnios)
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Why does the Doppler examination not have “cutting
edge”
And…..can we give it the edge ???
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Placental Bed
Umbilical Artery
Umbilical Vein
Lower LimbsKidneys
Descending Aorta
AortaCarotid Arteries
DV
Terminal IVC
IVC
RALV
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Effect of PIH on fetus- Fetal centralisation
1) Normoxemic centralisation
2) Hypoxemic centralisation
3) Decompensation
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1) Stage of Normoxemic centralisation
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The trans- villus gas exchange is affected
1. Spiral arterioles stenosis2. Sluggish flow in
Placental Lakes3. Trans Villus gas
exchange affected
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• The fetus adjusts to the milieu of privation
• Maintains oxygen supply to the fetal brain
• Decreased cerebral resistance Increased cerebral perfusion
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Placental Bed
Umbilical Artery
Umbilical Vein
Lower LimbsKidneys
Descending Aorta
AortaCarotid Arteries
DV
Terminal IVC
IVC
RALV
Cerebral circulation is maintained
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• Decreased cerebral resistance Increasing Diastolic velocities Decreasing MCA S/D ratio & PI ratio
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• More oxygenated blood from UV shunted through DV at the expense of the blood to the portal circulation
Fetal Liver also chips in….
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Umbilical Vein (LUV)
Intra hepatic portion of UV
Portal Sinus
Right
Portal vein
Ductus Venosus
IVC
Left
Por
tal
vein
Left
Hepatic
vein
Right
Hepatic
vein
Superior mesenteric vein & splenic vein
Left Liver Lobe
Right Liver Lobe
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• Decreased blood to the portal circulation
• Shrinking liver size Shrinking AC
• IUGR
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The Fetal vascular
adjustments overcome this
situation
Faster fetal circulation turnover maintains the fetal vascular PO2 in the face of sluggish placental circulation
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The fetal heart improves its inotropic force and helps to circulate the blood faster
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• Increased peripheral resistance Emptying of the peripheral venous compartment Increased venous return
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• But there is also concurrent increased tone of the Umbilical Arteries Decreased diastolic velocities
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• Increased UA resistance Decreasing Diastolic velocities Increasing UA S/D ratio & PI ratio
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Placental Bed
Umbilical Artery
Umbilical Vein
Lower LimbsKidneys
Descending Aorta
AortaCarotid Arteries
DV
Terminal IVC
IVC
RALV
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• Increased UA PI with decreased MCA PI
• Altered CPR
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(2)Stage of Hypoxemic centralisation
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• The compensatory mechanisms are no longer sufficient
• The fetal brain starts experiencing hypoxia
• The renal arteries have increased resistance
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• Decreasing blood supply to the kidneys Oliguria
• Cerebral hypoxia The brain stem autonomic reflexes get sluggish
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Most of the clinical tests pick up at this point
• NST is non reactive
• Beat to beat variability is affected
• Liquor is reduced
• Fetal movements reduced
• Fetal breathing pattern reduced
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(3) Decompensation
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• Further hypoxia
• Build up of tissue lactic acid
• Rapid shifting of O2 dissociation curve to right
• Acidosis
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• Further brain hypoxia Loss of fetal tone
• Failing heart “A” wave reversal of DV Pulsations of Umbilical Vein
• IUFD
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What shifts the fetus from Stage of compensated hypoxia to Stage
of decompensation
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Is it because of worsening of utero-placental resistance??
• That should lead to cardiac failure
• Hydrops should be seen in PIH patients
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Is it because of increasing blood flow in the cerebral circulation??
• Aneurysm of vein of Galen
• Rh incompatibility
– Babies die of Hydrops and cardiac failure
– No evidence of hypoxia in these cases
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The answer lies in venous flow
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• “S” wave Depends on “Venous Return” (Determined by After Load)
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• “D” wave How much the forward flow occurs immediately after the ventricular systole (Forward flow across AV valves)
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• “A” wave How much blood is remaining in RA after ventricular systole(Determined by Pre-load)
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Placental Bed
Umbilical Artery
Umbilical Vein
Lower LimbsKidneys
Descending Aorta
AortaCarotid Arteries
DV
Terminal IVC
IVC
RALV
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1) Stage of Normoxemic centralisation
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• IVC bringing deoxygenated blood gets oxygenated blood from DV (D)
• Both these flows travel together in terminal portion of IVC (T)
• The two flows remain separate because of pressure gradient between the two flows
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What keeps the two flows separate in the terminal IVC??
• There is no mechanical cordoning off……
• It is a principle of fluid dynamics that keeps the flows separate
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• “Boundary layer phenomenon”
• Simply put, the two currents in a tube remain separate, if the pressure difference between them is high
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Placental Bed
Umbilical Artery
Umbilical Vein
Lower LimbsKidneys
Descending Aorta
AortaCarotid Arteries
DV
Terminal IVC
IVC
RALV
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• IVC PSV approaches DV PSV
• Loss of separation
• Mixing of de-oxygenated & oxygenated blood flow
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Altered DV & IVC Pr Gradient Normal DV & IVC Pr Gradient
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Mount Everest in Utero
• Drop in pO2 of blood
reaching cerebral vasculature
• Drastic fall in O2 bound
to the fetal hemoglobin
• Fetal Hypoxia
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(2)Stage of Hypoxemic centralisation
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• Fetal Hypoxia More vasoconstriction Increasing VR Loss of pressure gradient More mixing of blood Decrease of PO2
• Cerebral hypoxia Vascular endothelium affected Cerebral hemorrhage
• Cerebral hypoxia Ischemic injury
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• Increasing VR Heart is not able to cope up with it More blood left over in the RA Increased “Pre-load”
• Loss of forward “A” wave
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Fetal Demise…..
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Date 3rd May,2010; GA 32 weeks
• G2 P1, 32 years old
• Previous LSCS
• BP 140/90, on T Labetolol
• Good Kick count
• Good Liquor
• Doppler ………
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Date 3rd May,2010; GA 32 weeks
MCA S/D= 4.1 Umb Art= AEDV
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• UA AEDV deliver or conserve??
• Good kick count/ adequate liquor
• BP 140/90
• GA 32 weeks
• Dilemma ……….
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Date 3rd May,2010; GA 32 weeks
DV PSV=31.67 cm/s IVC PSV=10.40 cm/s
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1) Stage of Normoxemic centralisation
Decision taken to conserve the pregnancy
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Date 31st May,2010; GA 36 weeks
• BP 140/90, on T Labetolol
• Decreased FM
• Reduced Liquor
• Doppler ………
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Date 31st May,2010; GA 36 weeks
MCA S/D=2.64 UA=AEDV
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Date 31st May,2010; GA 36 weeks
DV PSV=43.27 cm/s IVC PSV=45.06 cm/s
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2) Stage of Hypoxemic centralisation
Decision taken to deliver
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Other things to consider
• Fetal vascular adjustments through increasing VR, occur in chronic situations
• In acute conditions Tachycardia
• Tachycardia has very limited time frame
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• The fetal oxygenation can be affected by worsening of placental conditions Oxygenation of blood in placenta affected The blood arriving via DV itself is of low PO2
• Worsening of Toxemia, Maternal fever
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• Doppler values reflect adjustment of the fetus
• When fetus does not have time for adjustments, doppler values are of no value
• Abruptio Placenta
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Summary
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Uterine Artery Doppler
• An artery which feeds arterioles, has tri- phasic spectral flow
• Phase of reversal represents high resistance downstream
• Blood vessels which feed organs have bi- phasic spectral flow
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• This ensures continuous flow for the organ
• High resistance of spiral arterioles is symbolised by occurrence of diastolic notch
• Diastolic notch/ Uterine Artery RI are used to predict development of PIH
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Doppler for assessing fetal health
• Doppler values reflect fetal adjustment
• Arterial Dopplers only identify the subset of fetuses who are at risk of complications
• They do not tell you when to deliver
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• In 3rd Trimester, in the face of adverse utero-placental resistance, the UA may be minimally affected
• Abnormal UA/ MCA stage of Normoxaemic centralisation or beyond
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• Cerebro Placental Ratio (CPR)- MCA/UA PI
• Better predictor of the stage of hypoxemic centralisation
• Cut off 1.07
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• Venous dopplers reflect fetal oxygenation
• Increasing PSV of IVC suggests worsening of oxygen status
• Usually indicate timing of delivery
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Thank you