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3
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
ab
cd
Fig. 19.8a−e Doppler sonographic
display of the left uterine a.
throughout the course of pregnancy:
PI values tend to increase, marked
notch with increasing intensity, an additional systolic notch appears as the
pregnancy progresses (double notch).
a Gestational age: 22 weeks 5 days,
marked postsystolic notch, PI: 1.39.
b Gestational age: 25 weeks 0 days,
marked postsystolic notch, PI: 1.35
systolic notch = double notch.
c Gestational age: 27 weeks 2 days,
marked postsystolic notch, PI: 1.59,
systolic notch.
d Gestational age: 32 weeks 3 days,
marked postsystolic notch, PI: 1.72,
systolic notch.
e Gestational age: 33 weeks 3 days,
very marked postsystolic notch, PI
1.85, systolic notch.
e
ab
Fig. 19.9a−d Doppler sonographic
display of the umbilical a. through the
course of pregnancy. PI values rise,
Time average maximum velocity
(TAMX) declines.
a Gestational age: 25 weeks 0 days,
PI: 1.50, TAMX: 21 cm/s.
b Gestational age: 27 weeks 2 days,
PI: 1.11, TAMX: 26 cm/s.
c Gestational age: 32 weeks 3 days,
PI: 1.53, TAMX: 18 cm/s.
d Gestational age: 33 weeks 3 days,
PI: 1.94, TAMX: 16 cm/s.
174
cd
Fig. 19.10a−d Doppler sonographic
display of the MCA through the course
of pregnancy. PI values decline, TAMX
rises.
a Gestational age: 25 weeks 0 days,
PI: 2.37, TAMX: 17 cm/s.
b Gestational age: 27 weeks 2 days,
PI: 1.81, TAMX: 18 cm/s.
c Gestational age: 32 weeks 3 days,
PI: 1.34, TAMX: 22 cm/s.
d Gestational age: 33 weeks 3 days,
PI: 1.20, TAMX: 24 cm/s.
5—Patient with Antiphospholipid-Antibody Syndrome
ab
Advanced Topics
cd
Fig. 19.11 a−e Doppler sonographic
display of the aorta over the course of
pregnancy. PI values rise.
a Gestational age: 25 weeks 0 days,
PI: 1.90, TAMX: 38 cm/s, Time average velocity (TAV): 23 cm/s.
b Gestational age: 27 weeks 2 days,
PI: 2.30, TAMX: 40 cm/s, TAV:
25 cm/s.
c Gestational age: 32 weeks 3 days,
PI: 1.95, TAMX: 38 cm/s, TAV:
21 cm/s.
d Gestational age: 33 weeks 3 days,
PI: 3.75, TAMX: 28 cm/s.
e Gestational age: 33 weeks 3 days,
TAV: 23 cm/s.
ab
c
d
175
e
3
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
Fig. 19.12 a−d Doppler sonographic
display of the mitral valve, aortic arch,
IVC and DV at 33 weeks. As yet, there
is no decompensation.
a Mitral valve, E/A 쏝 1.
b Aortic arch, diastolic reverse flow,
centralization.
c IVC, preload index normal.
d V, preload index normal.
ab
cd
176
6—Marked Fetal Growth Restriction
6—Marked Fetal Growth Restriction
Mrs. S.D., age 32, gravida 1, para 0, was admitted for inpatient care at 36 weeks 4 days with marked fetal
Fig.
growth restriction and abnormal CTG (
19.13a).
Doppler values were highly abnormal in the arterial,
cardiac, and venous systems. Uterine aa. with bilateral
notches. Decision was to perform emergency cesarean
section
Infant male, 1580g (쏝3rd percentile), Apgar 4, UA
pH 6.95, UV pH 7.07, pCO
89 mmHg, pO26.5 mmHg,
2
BE −16.4 mmol/L, lactate 18.3 mmol/L. Unremarkable
maternal blood gas analysis (BGA) and lactate values.
Histopathological examination of the placenta showed
signs of chronic nutritional deficiency of the placenta
with a weight of only 200 g. A critical assessment
would be that admission was clearly delayed too long.
abc
Advanced Topics
def
ghi
Fig. 19.13 a−i Highly abnormal Doppler
readings in the arterial, cardiac, and
venous systems with an abnormal CTG
in a case of marked fetal growth restric-
tion at 36 weeks 4 days.
a Abnormal CTG: flat, no accelera-
tions.
b UA with marked reverse flow
throughout diastole, extreme de-
cline in TAV at 3 cm/s.
c Aorta. PI: 5.47, postsystolic notch
with reverse flow and end-diastolic
reverse flow. Quantitative flow
values extremely reduced, with a
TAMX of 19 cm/s and a TAV of
5 cm/s.
d MCA. PI reduced at 1.1, centraliza-
tion.
e Mitral valve. E/A쏜1, cardiac decom-
pensation.
f, g Tricuspid valve. E/A 쏝 1, tricuspid
insufficiency, cardiac decompensation.
h DV. Highly abnormal preload index
and TAV of 1 cm/s, cardiac decompensation.
i Right hepatic vein. Highly abnormal
preload index, TAV: 5 cm/s, cardiac
decompensation.
177
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
7—Twin Pregnancy with Twin-to-Twin Transfusion Syndrome
3
Mrs. J.L., age 37, gravida 3, para 1, status post fertility
clinic treatment, endometriosis, status post two laparoscopies. At 24 weeks of gestation referral for suspicion of twin-to-twin transfusion syndrome (TTTS) in
a monochorial twin pregnancy with a common
placenta.
On admission polyhydramnios was detected in the
second twin with an amniotic fluid index (AFI) of
34 cm, with the lowest pool being 12 cm.
ab c
The first twin exhibited oligohydramnios. The biometric values in both twins were appropriate to gestational age. The first twin with oligohydramnios
showed increased resistance indices in the UA and the
19.14, 19.15). The finding was not constant
Figs.
aorta (
and there was no centralization, no tricuspid incompetence; unremarkable venous Doppler findings
Fig. 19.16).
(
178
de f
ghi
jkl
Fig. 19.14 a−l Doppler sonographic dis-
play of the UA of the donor over the
course of pregnancy.
a−h Gestational age: 24 weeks 6 days.
Brief changes in the waveform of
the UA lasting less than 2 minutes.
i Gestational age: 25 weeks 3 days.
TAV diminished at 8 cm/s.
j Gestational age: 25 weeks 4 days.
TAV extremely diminished at
6cm/s.
k Gestational age: 28 weeks 5 days.
PI: 1.32, RI: 0.75, TAMX: 23 cm/s,
TAV: 14 cm/s.
l Gestational age: 34 weeks 4 days.
PI: 0.88, RI: 0.62, TAMX: 24 cm/s,
TAV: 14 cm/s.
7—Twin Pregnancy with Twin-to-Twin Transfusion Syndrome
The Doppler readings in the second twin were quali-
tatively normal, quantitatively, however, they were in-
Figs.
creased (
19.17−19.19). The length of the cervix
was 27 mm, i. e., shortened.
Consequently amnioreduction was performed and
repeated five days later. 1400 mL and 1500 mL were removed from the second amniotic sac. The pregnancy
Fig 19.15a−d Doppler sonographic
display of the donor’s aorta through
the course of pregnancy.
a Gestational age: 25 weeks 2 days.
PI: 1.55, RI: 0.81, TAMX: 19 cm/s,
TAV: 10 cm/s.
b Gestational age: 25 weeks 4 days.
TAV: 13 cm/s.
c Gestational age: 34 weeks 4 days.
PI: 2.00, RI: 0.87, TAMX: 51 cm/s.
d Gestational age: 36 weeks 6 days.
RI: 0.95.
ab
was then monitored twice a week, i.e., comprehensive
Doppler examinations of the arterial, cardiac, and
venous systems were performed (Figs.
19.14−19.19).
No further load-reducing taps were required. The
twins grew in accordance with their percentile, 5th for
the first, 25th for the second (Figs. 19.20,19.21).
Advanced Topics
Fig. 19.16a−d Doppler sonographic
display of the donor’s DV through the
course of pregnancy.
a Gestational age: 24 weeks 5 days.
TAV: 30 cm/s, V
b Gestational age: 25 weeks 3 days.
TAV: 19 cm/s.
c Gestational age: 28 weeks 5 days.
TAV: 17 cm/s.
d Gestational age: 35 weeks 6 days.
End-diastolic reverse flow, TAV:
14 cm/s, V
: 47 cm/s.
max
: 70 cm/s.
max
cd
a
cd
b
179
3
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
ab c
de f
g
Fig. 19.18a−c Doppler sonographic
display of the acceptor’s aorta.
a Gestational age: 25 weeks 2 days, PI:
1.22, RI: 0.71, TAMX: 47 cm/s, TAV:
30 cm/s.
Fig. 19.17 a−g Doppler sonographic
display of the UA of the acceptor
throughout the course of pregnancy.
a Gestational age: 24 weeks 4 days.
PI: 1.07, RI: 0.71, TAMX: 34 cm/s,
: 51 cm/s.
V
max
b, c Gestational age: 24 weeks 6 days.
Waveforms are unchanged.
b Gestational age: 25 weeks 4 days.
TAV: 22 cm/s.
d Gestational age: 25 weeks 3 days.
TAV: 20 cm/s.
e Gestational age: 25 weeks 4 days.
TAV: 21 cm/s.
f Gestational age: 28 weeks 5 days.
PI: 0.72, RI: 0.53, TAMX: 42 cm/s.
g Gestational age: 34 weeks 4 days.
PI: 0.82, RI: 0.56, TAMX: 27 cm/s,
TAV: 16 cm/s.
c Gestational age: 23 weeks 6 days. PI:
2.04, RI: 0.83, TAMX: 43 cm/s, TAV:
24 cm/s
Fig. 19.19a, b Doppler sonographic
display of the acceptor’s DV.
a Gestational age: 24 weeks 5 days.
TAV: 39 cm/s, V
b Gestational age: 25 weeks 3 days.
TAV: 47 cm/s.
: 98 cm/s.
max
180
ab
7—Twin Pregnancy with Twin-to-Twin Transfusion Syndrome
Fig. 19.20a−c Donor’s biometry.
a Gestational age: 24 weeks 4 days.
Thickness of dividing membrane
monochorionic/diamnionic: 0.5 mm.
Fig. 19.21a, b Acceptor’s biological
measurements.
a Gestational age: 24 weeks 5 days.
HC/TC: normal.
b Gestational age: 25 weeks 4 days.
Umbilical cord diameter: 22 mm.
b Gestational age: 24 weeks 5 days.
Heart circumference/thoracic circumference (HC/TC) normal at
85/158.
ab
The venous Doppler readings deteriorated in the
first (donor) twin at 35 weeks 6 days, leading to primary cesarean section.
Figures
19.22 and 19.23 show
comparisons between the curves obtained by Doppler
sonographic examination of the UA and the ductus venosus (DV) of the donor and acceptor between weeks
25 and 36.
First twin male, 1850 g (쏝5th percentile), 43 cm.
Apgar 10−10−10, UA pH 7.28.
c Gestational age: 25 weeks 4 days.
Umbilical cord diameter: 10 mm.
Advanced Topics
Second twin male, 2085 g (normal), 45 cm, Apgar 8−
9−9, UA pH 7.29.
Course was unremarkable and the infants were discharged home after 21 days.
Histopathology of the placenta confirmed a monochorial diamnionic twin placenta. The chorionic plate
showed the anatomical basis for TTTS, namely one
venovenous and one arteriovenous anastomosis.
181
Seven Cases Illustrating the Use of Doppler Ultrasound in Obstetrics
1.40
60
1.20
40
3
1.00
0.80
PI of UA.RI of UA.TAMX (cm/s) of UA.TAV (cm/s) of UA. V cm/s of DV
0.60
0.40
a
25 26 27 29 31 32 35 36
1.20
1.00
0.80
0.60
0.40
0.20
b
25
45
40
35
30
25
20
15
10
5
0
c
25
40
26
27
26
Weeks of gestation
313132
29
Weeks of gestation
29
27
Weeks of gestation
32
35
35
36
36
20
0
TAV (cm/s) of DV
25 26 27 29 32 36
Weeks of gestation
120
100
80
60
40
max
V (cm/s) of DV
20
0
25 26 27 29 32 36
Weeks of gestation
Donor Acceptor
Fig. 19.23a, b Curves comparing the Doppler sonographic ex-
aminations of the DV of the donor and acceptor between the
25th and 36th weeks of gestation.
a TAV of DV.
of DV.
b V
max
182
30
20
10
0
29
d
26 26
70
27
Weeks of gestation
323232
35
36
60
50
40
30
max
20
10
0
36
29 29
e
25
26 26
Donor
27
Weeks of gestation
Acceptor
35
컅 Fig. 19.22a−e Curves comparing the Doppler sonographic ex-
aminations of the UA of the donor and acceptor between the
25th and 36th weeks of gestation.
a PI of UA.
b RI of UA.
c TAMX of UA.
d TAV of UA .
of UA.
e V
max
20 Doppler Ultrasound in Gynecology
The potential of Doppler ultrasound examination of
the female pelvis has been greatly expanded since the
introduction of color Doppler, as it is now possible
simultaneously to display the anatomical structures in
B-mode and blood flow in color. Ultrasound probes
that include pulsed Doppler or color Doppler to display
the microcirculation have been available to practitioners for more than a decade. Now that measurement of blood perfusion, though still debated critically,
has become established in obstetrics relatively rapidly,
this chapter will attempt to present the current status
of Doppler ultrasound in gynecology.
In the course of the menstrual cycle marked changes
occur in the female sex organs, including the breast
and in the internal genital region.
Distinct perfusion changes can also be recorded as
part of the physiological maturation and aging of the
female genital organs from the beginning of puberty
into old age.
Finally, distinct perfusion changes are found in the
organs in the course of a number of benign inflammatory conditions and during the development of
malignant tumors.
These considerations clearly show that the early detection of neoplasms and the assessment of the significance of undefined adnexal findings can be improved
considerably by evaluating organ perfusion, adding
color-coded Doppler ultrasound to the purely morphological descriptions of structural changes used previously. For instance, the differential diagnosis of pelvic varices, which previously was difficult, can be facilitated considerably by the use of color Doppler (
20.1, 20.2).
Figs.
Advanced Topics
Fig. 20.1 Inconclusive cystic finding adjacent to the ovary. Fig. 20.2 Display of vascular perfusion with pelvic varicosities.
Fig. 20.3 Ectopic pregnancy with characteristic halo due to in-
tense vascularization of the chorion.
Fig. 20.4 Ovary with adjacent ectopic pregnancy showing
strong vascularization.
183