ROLE OF DOPPLER ULTRASONOGRAPHY IN TYPES OF DOPPLER USG CONTINUOUS WAVE DOPPLER PULSED DOPPLER:...

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Transcript of ROLE OF DOPPLER ULTRASONOGRAPHY IN TYPES OF DOPPLER USG CONTINUOUS WAVE DOPPLER PULSED DOPPLER:...

  • ROLE OF DOPPLER ULTRASONOGRAPHY IN

    OBSTETRICS

    PRESENTOR:DR.Y.RAMA CONSULTANT:DR.VEENU

    SENIOR RESIDENT:DR.AJAY KUMAR

  • BASICS OF DOPPLER

    • Pitch altered with change in relative motion b/n observer & object- DOPPLER SHIFT

    • FORMULA: fD= 2fo v cos 0/v

  • TYPES OF DOPPLER USG

    CONTINUOUS WAVE DOPPLER PULSED DOPPLER: Brief pulses of ultrasound waves Vessels visualised on gray scale and flow

    velocity patterns obtained

    SAMPLE VOLUME

    DOPPLER GATE

  • COLOR DOPPLER

    Stationary targets-B- mode image

    Signals from moving targets-display color

    Color assigned – direction of flow

    RED – TOWARDS

    BLUE-AWAY

  • DOPPLER INDICES

    PSV-peak systolic velocity-A

    EDV-end diastolic velocity-B

    Systolic /diastolic ratio

    RI-resistive index:(A-B)

    A

    PI-pulsatility index:(A-B)

    Mean

  • POWER DOPPLER

    • Detects energy or amplitude of doppler signals of moving blood

    • Independent of direction • Subtle amount of flow • Velocity –not obtained

  • INDICATIONS IN OBSTETRICS

    • LOCALISATION OF GESTATIONAL SAC • EARLY PREGNANCY FAILURE • FAILED TERMINATION OR RETAINED

    PRODUCTS OF CONCEPTION

    • PREDICTION OF PREECLAMPSIA • INTRAUTERINE GROWTH RETARDATION • TWIN GESTATION • FETAL HYDROPS AND ANEMIA • PLACENTAL AND CORD ANAMOLIES • STRUCTURAL ANAMOLIES OF FETUS

  • SAFETY OF DOPPLER IN PREGNANCY

    • Epidemiologic studies- association of LBW, delayed speech devn

    • More research

  • CURRENT RECOMMENDATIONS & GUIDELINES

    • Initial power setting lowest to produce adequate images-ALARA(As low as reasonably achievable) principle

    Operator-color flow box small, Exposure time, non stationary probe

    • Preexisting temperature elevation of mother • Sensitive tissues-head, brain, spine,eye

    (esp.

  • VESSELS AND NORMAL WAVEFORMS

  • UTERINE ARTERY:

    ANATOMY:

    branch of anterior division of internal iliac artery-on levator ani-isthmus-upwards on lateral sides of uterus in leaves of broad ligament

    NORMAL WAVEFORMS

  • DOPPLER MEASUREMENT AND WAVEFORM

    • At the cervico corporal junction

    NORMAL WAVEFORMS

    NORMAL PI1.45

    PREGNANT NON PREGNANT PREGNANT

  • Extravillous trophoblast from anchoring villi- into decidua-spiral artery

    innervated muscular

    vessels of high resis- tance--- passively dilated low resistance

    Vasodilatory peptides- increase in maternal blood flow

    NORMAL WAVEFORMS

    COILED SPIRAL ART

    UNCOILED SPIRAL ART

    EXTRAVILLOUS TROPHOBLASTIC CELLS

    SPIRAL ART

  • FETO MATERNAL CIRCULATION

    UMB V

    DUCTUS VENOSUS

    DESC.AORTA

    UMB ART

    IVC

  • UMBILICAL ARTERY Information on perfusion of fetoplacental

    unit

    Measured in extraabdominal portion

    NORMAL WAVEFORMS

  • NORMAL WAVEFORMS

    Growth of placenta ; increase in Cardiac output 1. increase in systolic & diastolic velocities 2.continuous forward flow 3.decrease in impedance

    3rd TM PI:1-1.5

    1st TM

  • UMBILICAL VEIN • From extra abdominal portion • Blood flow increases as gestation progresses-Pulsations

    disappear

    NORMAL WAVEFORMS

    1st TM 3rd TM

  • DUCTUS VENOSUS • Oblique section of

    upper abdomen or midsagittal section

    • Doppler measurements- sample volume at the initial or middle portion

    • Distal portion- contaminates IVC, HV

    NORMAL WAVEFORMS

  • Continuous forward flow throughout cardiac cycle

    BIPHASIC

    S wave---ventricular systole

    D wave---diastole

    A wave---forward flow at atrial

    contraction

    NORMAL WAVEFORMS

    D A

    S

  • THORACIC AORTA • Descending thoracic

    aorta flow throughout cardiac cycle

    NORMAL WAVEFORMS

  • MIDDLE CEREBRAL ARTERY

    Easier to detect

    Sensitive to detect IUGR

    Transverse axial view- slightly caudal than for BPD measurements

    Sample volume at the proximal part and the flow towards probe

    High systolic and low diastolic velocities– auto regulation

    NORMAL WAVEFORMS

    PI>1.45

  • LOCALISATION OF GESTATIONAL SAC

  • TO DIAGNOSE ECTOPIC:

    TRUE GESTATIONAL SAC

    Double decidual sign-

    •Oval & eccentric

    PSEUDOGESTATIONAL SAC

    Single echogenic layer

    •central

    ENDOMETRIUM

    ENDOMETRIUM ONLY EMBRYO & TROPHOBLAST

  • Ectopic: Sac - No peritrophoblastic flow

    Low velocity flow(

  • Ectopic: Adnexa- RING OF FIRE

    DD:Corpus luteal cyst-low resistance ;low vel flow

    Ectopic – Low resistance ;high vel flow

    Cardiac activity - M mode /color /power doppler

    MASS

    RING OF FIRE

    TO DIAGNOSE ECTOPIC:

  • • Interstitial & cornual ectopic-when no significant mass seen

    • CDI:increased flow

    TO DIAGNOSE ECTOPIC:

  • MONITOR METHOTREXATE THERAPY

    • To assess placental flow- absent or persistent-after treatment

  • CERCIVAL SCAR IMPLANTATION

    • Past H/O caesarean • Sac in LUS and local myometrial thinning • Significance:distinguish ongoing abortion dead

    embryo no peritrophoblastic activity

    • Catastrophic hemorrhage-even bladder involvement can occur

  • PREDICTION OF PREECLAMPSIA

    • Insufficient invasion of maternal spiral arteries by trophoblast

    impaired placental

    perfusion

  • Increase in RI or notching-dec placental flow

    NOTCH

    UTERINE ART

  • FAILED TERMINATION

    • RETAINED PRODUCTS OF CONCEPTION

    • large echogenic mass filling endometrial canal extending into myometrium

    • CDI- mass of vessels in the myometrium &high velocity flow

    • No flow-non viable –pass spontaneously

    • To plan D & C

    Vessels in myometrium

  • INTRAUTERINE GROWTH RESTRICTION

    • resistance in uteroplacental circulation

    • velocity in feeding arteries esp. Diastolic • Changes in uterine, umbilical, MCA, Aorta,

    ductus venosus

  • UTERINE ARTERY • Notch • Mean P.I. Of both uterine arteries >1.45 • placenta on one side- ipsilateral waveform reported

    NORMAL PI1.45

  • UMBILICAL ARTERY-PROGRESSIVE CHANGES

    ABSENT EDF

    REVERSAL EDF

    NORMAL

  • MIDDLE CEREBRAL ARTERY

    • Fetal hypoxia

    • Chemoreceptors sense

    • Inc flow to brain for oxygen(most sensitive)

    • diastolic vel(dec P.I.)-- REDISTRIBUTION

    NORMAL PI>1.45

  • THORACIC AORTA

    • Absent end diastolic velocity(adaptation to inc flow to brain)

    • Hypoxia,distress,IUGR impedance impedance in aorta in brain absent EDV

    NORMAL

  • DUCTUS VENOSUS

    Dec cardiac function

    Dec forward flow on atrialcontraction

    Reverse A wave

    NORMAL

    PSV>50cm/s

    A WAVE REVERSAL

    PSV

  • UMBILICAL VEIN

    • Decreased forward flow;no inc diastolic flow

    • Venous pulsations

    PULSATIONS

    NORMAL

  • SIGNIFICANCE OF DOPPLER

    • Not for diagnosis-positive predictive value for doppler indices is low

    • Prognosis and monitoring once diagnosed • If absent or reversed end diastolic flow in

    umb artery– very poor –prompt delivery

    • Fetal hypoxia before acidosis (CTG- changes only if acidosis)

  • STEROID ADMINISTRATION

    • Severe IUGR with absent EDF before 32w- no lung maturity – steroids given-improves lung maturity

    • CDI- assess cardiovascular response to steroids • Improves umbilical artery waveforms in 2/3rds • 1/3rd-deteriorate acutely-daily monitoring is imp-needs

    delivery

    TRANSIENT EDF PERSISTENT ARED

    BASELINE

    >24H

  • INTEGRATED FETAL TESTING

    • Abnormal doppler—BPS to be done • Timing of delivery depending only on

    doppler—compromise by prematurity

    • BPS done if abnormal doppler -- combination- safe intrauterine time

  • TWIN GESTATION

    • Monochorionic twins-single placenta--MC complication- twin to twin transfu