Biophysical ProfileBiophysical Profile& &

Color Doppler ultrasound Color Doppler ultrasound

in the high risk pregnancyin the high risk pregnancy

Presented by: Presented by:

Dr. Farzad AfzaliDr. Farzad AfzaliKasra Ultrasound ClinicKasra Ultrasound Clinic

BPP is applying to detect prenatal BPP is applying to detect prenatal

asphyxiaasphyxia

Doppler ultrasound is a modality for Doppler ultrasound is a modality for

detecting fetal hypoxia and acidosisdetecting fetal hypoxia and acidosis

Doppler can also predict later pre- Doppler can also predict later pre-

eclampsia at the 24-26 gestational weeks.eclampsia at the 24-26 gestational weeks.

Hypoxia: Low Oxygen tensionHypoxia: Low Oxygen tension

Asphyxia: Low Oxygen and high CO2Asphyxia: Low Oxygen and high CO2

Ischemia: Drop in blood flowIschemia: Drop in blood flow

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So, Doppler ultrasound can predict fetal So, Doppler ultrasound can predict fetal

distress sooner than BPPdistress sooner than BPP

Dr. farzad.afzaliDr. farzad.afzali

Prediction of the effect of an asphyxial Prediction of the effect of an asphyxial insult on the fetus requires a measure of : insult on the fetus requires a measure of : SeveritySeverity of the asphyxia. of the asphyxia. Duration Duration of the asphyxia.of the asphyxia.

18-48 hrs(Neuronal necrosis) 18-48 hrs(Neuronal necrosis)

48-72hrs(apper. of white 48-72hrs(apper. of white

matter macroph. &Astrocy.). matter macroph. &Astrocy.).

>4days cavitation >4days cavitation

visible on head U/Svisible on head U/S

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Fetal asphyxia may or may not be concomitant Fetal asphyxia may or may not be concomitant

with clinical presentation. (based on with clinical presentation. (based on

severity ,duration & location of insult)severity ,duration & location of insult)

Dr. farzad.afzaliDr. farzad.afzali

ComponentComponent DefinitionDefinitionFetal movementsFetal movements 3 body or limb movements3 body or limb movements

Fetal toneFetal tone One episode of active extension and One episode of active extension and flexion of the limbs; opening and flexion of the limbs; opening and closing of handclosing of hand

Fetal breathing Fetal breathing movementmovement

episode of >= 30 seconds in 30 episode of >= 30 seconds in 30 minutesminutes Hiccups are considered Hiccups are considered breathing activity.breathing activity.

Amniotic fluid volumeAmniotic fluid volume single 2 cm x 2 cm pocket is single 2 cm x 2 cm pocket is considered adequate.considered adequate.

Non-stress testNon-stress test 2 accelerations > 15 beats per 2 accelerations > 15 beats per minuteminute of at least 15 seconds duration.of at least 15 seconds duration.

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As you know, oligohydramnios may beAs you know, oligohydramnios may be

Mild AFI=5-8cmMild AFI=5-8cm

Moderate AFI=2-5cmModerate AFI=2-5cm

Sever AFI<2cm Sever AFI<2cm

only sever oligohydramnios is considered as an only sever oligohydramnios is considered as an

abnormal score.abnormal score.Dr. farzad.afzaliDr. farzad.afzali

Fetal movement and fetal tone develop Fetal movement and fetal tone develop

between 7.5 and 9 weeks’ menstrual age between 7.5 and 9 weeks’ menstrual age

Fetal breathing movements are Fetal breathing movements are

detectable by, at least 17-18 weeks’ detectable by, at least 17-18 weeks’

gestation gestation

The non-stress test is most reliable The non-stress test is most reliable

between 32 weeks and term (Ware, 1994).between 32 weeks and term (Ware, 1994).

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So ,BPP has a limited role for assessing So ,BPP has a limited role for assessing

fetal well being before 32 gestational fetal well being before 32 gestational

weeks.weeks.

Dr. farzad.afzaliDr. farzad.afzali

The non-stress test and fetal breathing The non-stress test and fetal breathing

movements are suppressed when the pH movements are suppressed when the pH

falls below 7.2. falls below 7.2.

If the fetal pH falls below 7.10, fetal tone If the fetal pH falls below 7.10, fetal tone

and fetal movements are abolished and fetal movements are abolished

(Vintzileos, 1987).(Vintzileos, 1987).

The biophysical profile score is The biophysical profile score is

continued for a maximum of 30 minutescontinued for a maximum of 30 minutes

Oligohydramnios is now defined as a Oligohydramnios is now defined as a

pocket of amniotic fluid < 2.0 x 2.0 cm pocket of amniotic fluid < 2.0 x 2.0 cm

(Manning, 1995A(Manning, 1995A

Perinatal Mortality and the Biophysical Profile ScorePerinatal Mortality and the Biophysical Profile Score

ScoreScore Perinatal Mortality/1000Perinatal Mortality/1000

8-108-10 1.861.86

66 9.769.76

44 26.326.3

22 94.094.0

00 285.7285.7

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I think,if you are working in a center that peri I think,if you are working in a center that peri

natal mortality is 50/1000 for preterm delivered natal mortality is 50/1000 for preterm delivered

fetus (otherwise normal), if you visit a fetus with fetus (otherwise normal), if you visit a fetus with

BPP= 4, you can wait till 35-37 gestational BPP= 4, you can wait till 35-37 gestational

weeks causionaly. (perinatal mortality for BPP = weeks causionaly. (perinatal mortality for BPP =

4 is 26/1000)4 is 26/1000)

Dr. farzad.afzaliDr. farzad.afzali

Color Doppler ultrasound in the high Color Doppler ultrasound in the high risk pregnancyrisk pregnancy

Doppler ultrasound has three view of applying in the OB& Doppler ultrasound has three view of applying in the OB&

GYN field.GYN field.

1 – direct view for example in ovarian torsion or detecting 1 – direct view for example in ovarian torsion or detecting

vascularity of a fibroma.vascularity of a fibroma.

2 – easy conceptional view for example to differentiating a 2 – easy conceptional view for example to differentiating a

benign ovarian mass from malignant one.benign ovarian mass from malignant one.

3- deep conceptional view for example in detecting fetal 3- deep conceptional view for example in detecting fetal

hypoxia & acidosis in pregnancy hypoxia & acidosis in pregnancy

Dr.Farzad AfzaliDr.Farzad Afzali

Uterine artery

An early stage in fetalAn early stage in fetal adaptation to hypoxemiaadaptation to hypoxemia

- - central redistribution of blood flowcentral redistribution of blood flow ( brain-sparing reflex)( brain-sparing reflex)

- increased blood flow to protect the increased blood flow to protect the brain, heart, and adrenals brain, heart, and adrenals

- reduced flow to the peripheral and reduced flow to the peripheral and placental circulations placental circulations

Doppler wave form of early stage ofDoppler wave form of early stage of fetal hypoxemiafetal hypoxemia

- increased end-diastolic flow in the increased end-diastolic flow in the middle cerebral artery (lower MCA middle cerebral artery (lower MCA pulsatility index or resistance index)pulsatility index or resistance index)

- decreased end-diastolic flow in the decreased end-diastolic flow in the umbilical artery (higher umbilical umbilical artery (higher umbilical artery RI or systole-to-diastole [S/D] artery RI or systole-to-diastole [S/D] ratio ratio

Long term outcomes need to be Long term outcomes need to be examinedexamined

• Middle cerebral arteryMiddle cerebral artery

• Aorta Aorta

• Umbilical arteryUmbilical artery

• Uterine arteryUterine artery

• IVCIVC

• Ductus venosusDuctus venosus

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The first Doppler change is rising peak The first Doppler change is rising peak velocity in ductus venosum.velocity in ductus venosum.

It can not be measured by Doppler It can not be measured by Doppler precisely because it is an angle related precisely because it is an angle related index.index.

The middle cerebral artery (MCA) in the The middle cerebral artery (MCA) in the fetal brainfetal brain

- normally high-impedancenormally high-impedance

- most accessible to U/S imagingmost accessible to U/S imaging

- more than 80% of cerebral blood- more than 80% of cerebral blood

   

MCAMCA

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Average of both MCAs must be calculated Average of both MCAs must be calculated

for more precise result.for more precise result.

Dr.farzad AfzaliDr.farzad Afzali

Fetal AortaFetal Aorta

commentcomment PI of thoracic aorta is sum of all branches’ PI PI of thoracic aorta is sum of all branches’ PI

below it, specially both umbilical & femoral below it, specially both umbilical & femoral

arteries.arteries.

It means that increased impedance against It means that increased impedance against

umbilical artery causes increasing PI of thoracic umbilical artery causes increasing PI of thoracic

aorta.aorta.

Placental insufficiency inhibits acid extraction Placental insufficiency inhibits acid extraction

from fetal body and causes acidosisfrom fetal body and causes acidosis

continuecontinue

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Acidosis causes peripheral arterial spasm & Acidosis causes peripheral arterial spasm &

rises PI of femoral arteries, consequently rises PI of femoral arteries, consequently

increases thoracic aorta PI.increases thoracic aorta PI.

If fetal acidosis has an intrinsic cause,it will be If fetal acidosis has an intrinsic cause,it will be

expected that femoral artery PI will be effected expected that femoral artery PI will be effected

more than umbilical PI.more than umbilical PI.

Dr. Farzad AfzaliDr. Farzad Afzali

The damage that obliterate The damage that obliterate small muscular arteries in small muscular arteries in placental tertiary stem villiplacental tertiary stem villi

- absent flow or even reversed flowabsent flow or even reversed flow

- - commonly associated with severe commonly associated with severe IUGR and oligohydramniosIUGR and oligohydramnios

Umbilical arteryUmbilical artery

Uterine arteryUterine artery

The best predictor of PIH is notch in the The best predictor of PIH is notch in the

uterine artery & RI>58 % after 24 w of uterine artery & RI>58 % after 24 w of

gestation.gestation.

A/C ratio > 2.5 is considered pathologic.A/C ratio > 2.5 is considered pathologic.

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I think that RI of uterine artery more than 75% (2 I think that RI of uterine artery more than 75% (2

standard deviation above mean) must be standard deviation above mean) must be

considered as a limit for prediction of considered as a limit for prediction of

preeclampsia.preeclampsia.

Dr.farzad AfzaliDr.farzad Afzali

Uterine arteryUterine artery

Pathological changes in venous flows Pathological changes in venous flows with FGRwith FGR

Venous indices reflect :Venous indices reflect : ventricular functionventricular function Fetal hypoxiaFetal hypoxia Myocardial lactic acidosisMyocardial lactic acidosis

Decrease cardiac output secondary to myocardial Decrease cardiac output secondary to myocardial dysfunctiondysfunction

• Rise in CVPRise in CVP

• Increase in reverse flow in atrial systoleIncrease in reverse flow in atrial systole

• Transmitted down venous system - the further from the Transmitted down venous system - the further from the heart the greater degree of cardiac dysfunctionheart the greater degree of cardiac dysfunction

Pattern continuedPattern continued

• DV ‘a’ wave decreaseDV ‘a’ wave decrease

• Reverse EDF UA -- Reverse ‘a’ wave DVReverse EDF UA -- Reverse ‘a’ wave DV

• Pulsatile UVPulsatile UV

• Constriction of cerebral circulationConstriction of cerebral circulation

• Death within 96 hoursDeath within 96 hours

IVCIVC

Ductus Venosus - normalDuctus Venosus - normal

Normal progression through pregnancy is fNormal progression through pregnancy is for a decrease in proportion of blood flow fror a decrease in proportion of blood flow from umbilical vein - 40 to 15% of total voluom umbilical vein - 40 to 15% of total volume 2nd to 3rd trimesterme 2nd to 3rd trimester

Leads to more flow to liverLeads to more flow to liver Increase in blood flow velocity with Increase in blood flow velocity with

gestational agegestational age

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We can find ductus venosum by rising We can find ductus venosum by rising color scale to 50cm/sec at level of color scale to 50cm/sec at level of umbilical artery.umbilical artery.

It cause other vessles except aorta & It cause other vessles except aorta & ductus venosum will be disappeared.ductus venosum will be disappeared.

DUCTUS VENOSUMDUCTUS VENOSUM

Umbilical veinUmbilical vein

Umbilical vein displays pulsatility in first Umbilical vein displays pulsatility in first

trimester but this disappears with trimester but this disappears with

advancing gestation in the pregnancy advancing gestation in the pregnancy

unaffected by FGRunaffected by FGR

The data on MCA PI on 5 year follow up is The data on MCA PI on 5 year follow up is

very worrying as the brain sparing effect very worrying as the brain sparing effect

commonly occurs before venous Doppler commonly occurs before venous Doppler

disturbancesdisturbances

In clinical practice, it is necessary to carry In clinical practice, it is necessary to carry

out serial Doppler investigations to out serial Doppler investigations to

estimate the duration of fetal blood flow estimate the duration of fetal blood flow

redistribution. redistribution.

The onset of abnormal venous Doppler The onset of abnormal venous Doppler

results indicates deterioration in the fetal results indicates deterioration in the fetal

condition and iatrogenic delivery should condition and iatrogenic delivery should

be considered be considered

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It seems that arterial changes can lead directly It seems that arterial changes can lead directly

to non-reactive NST ,asphyxia and death to non-reactive NST ,asphyxia and death

because of brain damage.because of brain damage.

Venous changes are signs of fetal heart failure, Venous changes are signs of fetal heart failure,

so fetal death is due to heart damage.so fetal death is due to heart damage.

Therefore ,fetal hypoxia & acidosis can end to Therefore ,fetal hypoxia & acidosis can end to

fetaldeath,either by cardiac or brain failure.fetaldeath,either by cardiac or brain failure. Dr. Farzad AfzaliDr. Farzad Afzali

conclusionconclusion

• The best predictor for fetal acidemia is The best predictor for fetal acidemia is

PI of thoracic aorta.PI of thoracic aorta.

• The best predictor of fetal hypoxia is PI The best predictor of fetal hypoxia is PI

of MCA.of MCA.

PI of MCA/PI of TA must be more than 0.9 before PI of MCA/PI of TA must be more than 0.9 before

30,less than 0.8 before the 34 & less than 0.75 30,less than 0.8 before the 34 & less than 0.75

before the 36 weeks of pregnancy.before the 36 weeks of pregnancy.

PI of MCA/ PI of UA must be >1.08 during PI of MCA/ PI of UA must be >1.08 during

pregnancy.pregnancy.

The larger values are abnormal & termination The larger values are abnormal & termination

may be considered after 35-37 weeks of may be considered after 35-37 weeks of

pregnancy.pregnancy.

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I think PI MCA/ PI umb artery is more I think PI MCA/ PI umb artery is more reliable than PI MCA / PI Aortareliable than PI MCA / PI Aorta

Reverse flow in the umbilical artery, Reverse flow in the umbilical artery,

along with pathologic waveform in the along with pathologic waveform in the

venous system are the best predictor venous system are the best predictor

of sever fetal distress, so termination of sever fetal distress, so termination

of pregnancy must be considered as of pregnancy must be considered as

soon as possible.soon as possible.

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It must be stressed that :It must be stressed that :

Delivered fetus with mild fetal hypoxia (only PI of Delivered fetus with mild fetal hypoxia (only PI of

MCA is lower than 1.5) has normal condition & MCA is lower than 1.5) has normal condition &

apgar in the labor room, but in future, it has apgar in the labor room, but in future, it has

higher risk for mean IQ be lower than non higher risk for mean IQ be lower than non

hypoxemic fetuses.hypoxemic fetuses.

Dr. Farzad AfzaliDr. Farzad Afzali

Fetal biometry and arterial DopplerFetal biometry and arterial Doppler - the early compensatory phase of IUGR- the early compensatory phase of IUGR

Venous Doppler, FHR analysis, and the Venous Doppler, FHR analysis, and the biophysical profilebiophysical profile

- data on the later stages(commonly - data on the later stages(commonly associated with fetal acidosis and impending associated with fetal acidosis and impending cardiovascular collapse) cardiovascular collapse)

When used in conjunction with When used in conjunction with other other diagnostic toolsdiagnostic tools, Doppler U/S improve , Doppler U/S improve outcomes in growth-restricted fetuses.outcomes in growth-restricted fetuses.