Doppler Ultrasound in Obstetrics and Gynecology

Preface
Contents
1: Doppler Sonography: A Brief History
1.1 Introduction
1.2 Christian Andreas Doppler and the Doppler Theory
1.2.1 Early Life
1.2.2 The Doppler Theory
1.2.3 Verification of Doppler’s Theory
1.2.4 Later Life
1.3 Early Application of Doppler Theory
1.4 Development of Spectral Doppler Ultrasonography
1.5 Development of Color Doppler Ultrasonography
1.6 Development of Doppler Sonography in Obstetrics
1.6.1 Early Work
1.6.2 Doppler Ultrasound of the Umbilical Artery
1.6.3 Doppler Ultrasound of the Fetal Venous Circulation
1.6.4 Doppler Ultrasound of the Fetal Cerebral Circulation
1.6.5 Doppler Ultrasound of the Miscellaneous Fetal Arterial Circulation
1.6.6 Doppler Ultrasound of the Uteroplacental Circulation
1.6.7 Fetal Doppler Echocardiography
1.6.8 Promotion of Fetal Doppler
1.7 Doppler Application in Gynecology
References
2: Physical Principles of Doppler Ultrasonography
2.1 Propagation of Sound
2.2 Propagation Speed of Sound
2.3 Wavelength, Frequency, Pulse
2.4 Amplitude, Power, Intensity
2.5 Ultrasound and Piezoelectric Effect
2.6 Characteristics of Sound Transmission in a Medium
2.7 Doppler Effect
2.8 Doppler Ultrasound
2.9 Backscattering
2.10 Magnitude of Doppler Shift
2.11 Angle Dependence of Doppler Shift
References
3: Spectral Doppler: Basic Principles and Instrumentation
3.1 Doppler Signal Processing
3.2 Reception-Amplification
3.3 Demodulation
3.4 Direction Discrimination
3.5 High-Pass and Low-Pass Filters
3.6 Doppler Spectral Analysis
3.7 Fourier Transform Spectral Analysis
3.8 Limitations of FFT Spectral Analysis
3.8.1 Spectral Variance
3.8.2 Intrinsic Spectral Broadening
3.9 Analog Fourier Spectral Analysis
3.10 Autoregression Analysis
3.11 Continuous-Wave Doppler Ultrasonography
3.12 Pulsed-Wave Doppler Ultrasonography
3.13 Doppler Sample Volume
3.14 Artifacts of Spectral Doppler Sonography
3.15 Nyquist Limit
3.16 Implications of Aliasing
3.17 Range-Velocity Resolution
3.18 Mirror Imaging
3.19 Duplex System
3.19.1 Principles of the Duplex Doppler System
3.19.2 Optimal Configuration of a Duplex System: Imaging Versus Doppler System
3.19.3 Duplex Implementation
3.19.4 Electronic Array Scanner
3.20 Integration of the Doppler and Imaging Functions in Array Transducer
3.21 Doppler Display
References
4: Spectral Doppler Sonography: Waveform Analysis and Hemodynamic Interpretation
4.1 Spectral Doppler Sonogram
4.2 Doppler Frequency Shift Envelopes
4.2.1 Maximum Frequency Shift Envelope
4.2.2 Mean Frequency Shift Envelope
4.2.3 First Moment Envelope
4.3 Hemodynamic Information from Doppler Sonography
4.3.1 Flow Detection
4.3.2 Flow Direction
4.3.3 Flow Velocity Profile
4.3.4 Doppler Flow Quantification
4.4 Principle of Doppler Flowmetry
4.5 Doppler Velocity Measurement
4.5.1 Uniform Insonation Method
4.5.2 Assumed Velocity Profile Method
4.6 Determination of Vascular Luminal Area
4.7 Determination of the Angle of Insonation
4.8 Alternative Methods of Doppler Flowmetry
4.9 Doppler Waveform Analysis and Doppler Indices
4.10 Comprehensive Waveform Analysis
4.11 Choice of Indices
4.12 Sources of Variance of the Doppler Indices
4.13 Hemodynamic Basis of Doppler Waveform Analysis
4.14 Experimental Approaches to Hemodynamic Validation of Doppler Indices
4.15 Arterial Input Impedance: Basic Concepts and Relevance to Doppler Waveform Analysis
4.16 Doppler Indices and Peripheral Resistance
4.17 Doppler Indices and Input Impedance
4.18 Doppler Indices and Central Circulation
4.19 Placental Vascular Changes and Abnormal Doppler Waveforms
References
5: Venous Hemodynamics
5.1 Blood Velocity in Veins
5.1.1 Laminar Flow, Turbulent Flow, or Whirls
5.1.2 Parabolic Flow and Other Velocity Profiles
5.2 Viscosity Effect on Venous Flow
5.3 Pressure Gradient and Resistance in Venous Flow
5.4 Measuring Blood Flow in Veins
5.4.1 Determining Blood Velocity
5.4.2 Determining Vessel Diameter
5.5 Pulsation in Veins
5.5.1 Transmission Lines
5.5.2 Wave Reflections
5.5.3 Direction of Pulse and Blood Velocity
5.5.4 Compliance and Reservoir Function of the Umbilical Vein
5.5.5 Source of Pulse
5.5.6 Cardiac Function and Waveform
References
6: Doppler Color Flow: Basic Principles
6.1 Introduction
6.2 Principles of Doppler Color Flow Mapping
6.2.1 Multigated Doppler Interrogation
6.2.2 Color Doppler Signal Analysis
6.2.3 Instrumentation
6.2.4 Color Flow Processor
6.2.5 Transducers for Two-Dimensional Doppler Color Flow Mapping
6.2.6 Color Mapping
6.2.7 Color Classification
6.2.8 Color Perception
6.2.9 Color Encoding of Doppler Flow Signals
6.2.10 Color Mapping of Direction of Flow
6.2.11 Clinical Utility of Color Flow Mapping
6.2.12 Color Mapping of Variance
6.2.13 Formation of a Color Frame
6.2.14 Persistence
6.2.15 Frame Rate
6.2.16 M-Mode Color Frame Formation
6.3 Operational Considerations
6.3.1 Transducer Frequency
6.3.2 Pulse Repetition Frequency
6.3.3 Doppler Color Flow Gain
6.3.4 High-Pass Filter (Wall Filter, Clutter Filter)
6.4 Limitations of Color Doppler
6.4.1 Aliasing
6.4.2 Range Ambiguity
6.4.3 Temporal Ambiguity
6.4.4 Angle of Insonation
6.4.5 Wall Motion Ghost Signals
6.4.6 Mirroring
6.5 Color Flow Visualization
6.6 Power Doppler
6.6.1 Directional Power Doppler
6.6.2 Power Doppler Microvascular Flow Imaging
6.7 Four-Dimensional Doppler Color Flow Mapping
References
7: Biosafety of Diagnostic Doppler Ultrasound
7.1 Introduction
7.2 Acoustic Output from Diagnostic Scanners
7.3 Safety Standards and Regulation
7.4 Thermal Index
7.5 Mechanical Index
7.6 What Can the Operator Do?
7.7 Evidence from Human Studies
7.8 Guidelines and Recommendations
References
8: Fetal Cardiovascular Physiology
8.1 Fetal Oxygenation
8.2 Development of Fetal Basal Cardiovascular Function
8.3 Fetal Cardiovascular Function During Stress
8.4 Fetal Hypoxia
8.5 Fetal Cardiovascular Responses to Acute Hypoxia
8.6 Functional Importance of the Fetal Cardiovascular Responses to Acute Hypoxaemia
8.7 Physiology Underlying the Fetal Cardiovascular Responses to Acute Hypoxaemia
8.7.1 Afferent Neural Pathways
8.7.2 Efferent Neural Pathways
8.7.3 Endocrine Mechanisms
8.7.4 Local Mechanisms
8.8 Maturation of the Fetal Cardiovascular Responses to Acute Hypoxaemia
8.9 Modulation of Fetal Cardiovascular Function by Adverse Intrauterine Conditions
References
9: Maternal Cardiovascular Physiology and Assessment
9.1 Introduction
9.2 Blood Pressure Regulation
9.3 Clinical Consequences of Circulatory Maladaptation to Pregnancy
9.4 Magnitude of Healthy Circulatory Changes
9.5 Assessment of Cardiac Output
9.6 Practical Assessment of Stroke Volume
9.7 Summary
References
10: Venous Doppler Sonography in Pregnancy
10.1 Aspects of Venous Physiology
10.2 The Venous Doppler Waveform Explained
10.3 Technique of Intrahepatic and Intrarenal Venous Doppler Sonography
10.4 Methodologic Improvement of Venous Doppler Flow Imaging
10.5 Venous Doppler Flow Characteristics in Normal and Pathologic Pregnancies
10.5.1 Normal Pregnancy
10.5.2 Preeclampsia
10.5.3 Gestational and Essential Hypertension
10.5.4 Normotensive Pregnancies with Newborns Small for Gestational Age
10.6 Relevance of Maternal Venous Hemodynamics Assessment
10.6.1 Pathophysiology of Preeclampsia and Gestational Hypertension
10.6.2 Screening for Preeclampsia
10.6.3 Management
10.7 Pitfalls and Limitations of Maternal Venous Hemodynamics Assessment
10.8 Conclusion
References
11: Relationship Between Maternal and Fetal Cardiovascular Function
11.1 Overview of Maternal Cardiovascular Function in Health and Disease
11.2 Uterine Artery Doppler, Trophoblast Invasion, and Maternal Cardiovascular Function
11.3 Maternal Cardiovascular Function and Fetal Doppler Indices: Umbilical Artery, Middle Cerebral Artery, and Ductus Venosus
11.4 Maternal Cardiovascular Function, Fetal Growth, and Birthweight
References
12: Intrauterine Blood Flow and Postnatal Development
12.1 Background
12.1.1 Neurodevelopmental Outcome in FGR
12.1.2 FGR and Cardiovascular Morbidity
12.2 Postnatal Implications of Abnormal Fetal Blood Flow
12.2.1 Neonatal Outcome
12.3 Long-Term Neurodevelopmental Implications
12.3.1 Umbilical Artery Blood Flow
12.3.1.1 The Lund-Malmö Study
Early-Onset FGR Cohort—Background Material
Neurological and Cognitive Development
12.3.2 Fetal Cerebral Blood Flow
12.3.3 Fetal Aortic Blood Flow
12.3.3.1 The Lund-Malmö Study
Late-Onset FGR Cohort—Background Material
Neurological and Cognitive Development at 7 Years of Age
Cognitive Outcome at 18 Years of Age
Retinal Neural Morphology and Function
12.4 Postnatal Brain Morphology
12.5 Cardiovascular Morphology and Function
12.5.1 Umbilical Artery Blood Flow
12.5.1.1 The Lund-Malmö Study
Early-Onset FGR Cohort
12.5.2 Fetal Aortic Blood Flow
12.5.2.1 The Lund-Malmö Study
Late-Onset FGR Cohort
12.5.3 Fetal Cerebral Blood Flow
12.6 Conclusion
References
13: Fetal Renal Artery
13.1 Embryology
13.2 Anatomy
13.3 Urine Production
13.4 Blood Flow in the Aorta and Through the Fetal Kidneys by Gestational Age
13.5 The Renal Artery Blood Flow and Resistance
13.6 Ultrasound Assessment of the Fetal Kidney
13.7 Methods to Quantify Fetal Renal Artery Flow and Resistance
13.8 Normal Values over Gestational Age
13.9 Changes with FGR
13.10 Changes with Fetal Anemia
13.11 Changes Associated with Oligohydramnios or Polyhydramnios
13.12 Changes with Renal Anomalies
13.13 Changes with Exposure to Medications
References
14: Umbilical Doppler Velocimetry: Normative Data and Diagnostic Efficacy
14.1 Introduction
14.2 Doppler Interrogation of the Umbilical Artery
14.3 Pulsed-Wave Doppler Interrogation
14.4 Continuous-Wave Doppler Interrogation
14.5 Doppler Display and Archiving
14.6 Descriptor Indices of the Umbilical Arterial Doppler Waveform
14.7 Reproducibility of Umbilical Arterial Doppler Indices
14.8 Continuous-Wave Versus Pulsed-Wave Doppler Indices
14.9 Factors Influencing the Umbilical Artery Doppler Indices
14.9.1 Doppler Sampling Site
14.9.2 Short-Term Temporal Variations: The Circadian Rhythm
14.9.3 Long-Term Temporal Variations: Gestational Age Effect
14.9.4 Fetal Heart Rate
14.9.5 Fetal Breathing
14.9.6 Behavioral States
14.9.7 Blood Viscosity
14.9.8 Maternal Posture and Umbilical Arterial Doppler Indices
14.9.9 Maternal Exercise and Yoga
14.10 Reference Ranges for Umbilical Artery Doppler Indices
References
15: Fetal Aortic Isthmus and Descending Aorta
15.1 Fetal Aortic Isthmus
15.1.1 Importance
15.1.2 Anatomical Features
15.1.3 Doppler Recordings of the Aortic Isthmus Flow Velocity
15.1.4 Fetal Growth Restriction
15.1.4.1 Intrauterine Hypoxia and Changes in the Aortic Isthmus Blood Flow
15.1.4.2 Early-Onset Fetal Growth Restriction
15.1.4.3 Late-Onset Fetal Growth Restriction
15.1.5 Aortic Isthmus and Coarctation of the Aorta
15.1.6 Aortic Isthmus in Twin Pregnancies
15.1.7 Maternal Hyperoxygenation and Aortic Isthmus
15.2 Fetal Descending Aorta
15.2.1 Fetal Aortic Doppler Velocimetry
15.2.1.1 Aortic Flow Estimation
15.2.1.2 Aortic Velocity Waveform Analysis
15.2.2 Fetal Aortic Flow in Uncomplicated Pregnancies
15.2.3 Intrinsic Influences on Fetal Aortic Flow and Flow Indices
15.2.4 Fetal Aortic Blood Flow during Labor
15.2.5 Pathophysiologic Changes of Fetal Aortic Flow during Intrauterine Hypoxia
15.2.6 Clinical Studies
15.2.6.1 Fetal Cardiac Arrhythmias
15.2.6.2 Fetal Anemia
15.2.6.3 Diabetes Mellitus
15.2.6.4 Fetal Growth Restriction
15.2.7 Aortic Doppler Velocimetry as a Diagnostic Test of FGR and Fetal Hypoxia
15.3 Summary
References
16: The Cerebroplacental Ratio and Hypoxic Index in the Prediction of Fetal Outcome
16.1 Fetal Cerebral Flow Adaptation to Hypoxia
16.2 Examination Technique
16.2.1 Human Investigations (Duplex B, Pulsed Wave Doppler, and Color Doppler)
16.2.2 Animal Investigations (Implanted Doppler Sensors)
16.3 Cerebral Hemodynamics and Doppler Indices
16.3.1 Cerebral Resistance to Flow
16.3.2 The Cerebroplacental (Cerebral-Umbilical) Ratio: The History
16.3.3 Cerebroplacental Ratio for Evaluating pO2 Changes
16.3.4 Effect of Fetal Heart Rate on Doppler Vascular Resistance Indices
16.3.5 The Cumulative Reduction in the CPR and the Hypoxic Index
16.4 Cerebral Circulation in Normal Pregnancy
16.4.1 Cerebral Flow Changes with Gestational Age
16.4.2 Variations According to the Site of Examination
16.4.3 Cerebral Flow Changes with Behavioral States
16.5 Clinical Significance of Cerebral and Cerebral/Umbilical Indices
16.5.1 Cerebral Flow in Growth-Restricted and Hypoxic Human Fetuses
16.5.2 Cerebroplacental Ratio Change in Cases of Hypoxia and IUGR
16.5.3 Cerebroplacental Ratio and Perinatal Outcome
16.5.4 Hypoxic Index for Predicting Effect of Hypoxia
16.5.5 Cerebrovascular Reactivity Tests (O2, CO2)
16.6 Cerebral Flow Response to Induced Hypoxia and Drugs in Animal Models
16.6.1 Cerebroplacental Ratio and Mechanically Induced Hypoxia
16.6.2 Cerebral Flow and Long-Term Nicotine Treatment (Animal Model)
16.6.3 Cerebral Flow and Long-Term Cocaine Treatment (Animal Model)
16.6.4 Cerebroplacental Ratio and Acute Drug Effect
16.7 Cerebral Resistance Index, Flow Redistribution Ratio (CPR), and Hypoxic Index in Specific Human Pathologies
16.7.1 Cerebral Resistance Index and CPR in Acute Reversible Hypoxia: Prediction of Abnormal Fetal Heart Rate at Delivery
16.7.1.1 Without Placental Insufficiency: Maternal Anemia
16.7.1.2 With Placenta Insufficiency (Malaria)
16.7.2 CPR in Nonreversible Hypoxia (Hypertension in Pregnancy) Prediction of Abnormal Fetal Heart Rate at Delivery
16.7.3 Cerebral Flow During Maternal Anesthesia
16.8 CPR Change During Febrile Episodes
16.9 Clinical Effectiveness and Guidelines
16.10 Summary of the Design, Validation, and Significance of the Cerebroplacental Ratio and the Hypoxic Index
16.11 Conclusion
References
17: The Cerebroplacental Ratio
17.1 Fetal Brain Circulation and Hypoxia
17.2 Fetal Brain Circulation
17.3 Fetal Size/Growth and Brain Circulation
17.4 Fetal Brain-Sparing and Brain Vasodilation
17.5 Pioneering Studies on the Cerebroplacental Ratio
17.6 Normal Values of the Cerebroplacental Ratio
17.7 Longitudinal Changes of the Cerebroplacental Ratio
17.8 Should the Cerebroplacental Ratio Be Evaluated in all Pregnant Women?
17.9 Can a Reduced Cerebroplacental Ratio Predict an Abnormal Fetal Heart Rate During Labor?
17.10 The Cerebroplacental Ratio in Fetal Growth Restriction
17.11 The Cerebroplacental Ratio in Other High Risk Conditions
17.12 The Cerebroplacental Ratio and Maternal Serum Biomarkers
17.13 Conclusion
References
18: Cerebral Blood Flow Velocity Waveforms and Fetal Anemia
18.1 Causes of Fetal Anemia
18.2 Which Cerebral Vessel to Assess
18.3 Technique for Measurement of Middle Cerebral Artery Doppler
18.4 Historical Development of Middle Cerebral Artery Technique
18.5 Practical Application of MCA Peak Systolic Velocity to Red Cell Alloimmunization
18.6 False Positives with Middle Cerebral Doppler
18.7 The Middle Cerebral Doppler in Alloimmunization
18.8 The Middle Cerebral Doppler in Infection
18.9 The Middle Cerebral Doppler in Fetal Hydrops
18.10 The Middle Cerebral Doppler in Twin Anemia-Polycythemia Syndrome
18.11 The Middle Cerebral Doppler in Fetomaternal Hemorrhage
References
19: First- and Second-Trimester Doppler Velocimetry of the Uteroplacental Circulation
19.1 Physiological Changes in the Uteroplacental Circulation During Pregnancy
19.1.1 Abnormal Changes in the Uteroplacental Circulation
19.2 Relationship Between the Uteroplacental Circulation and the Maternal Systemic Circulation
19.3 First-Trimester Doppler Velocimetry of the Uteroplacental Circulation for the Prediction of Fetal Growth Restriction and Pre-eclampsia
19.4 Protocol for Recording the Uterine Artery Doppler in the First Trimester
19.5 First-Trimester-Combined Screening Algorithms for Fetal Growth Restriction and Pre-eclampsia
19.5.1 Maternal Risk Factors
19.5.2 Serum Biomarkers
19.5.3 The Uterine Artery Pulsatility Index in Combination with Other Tests
19.6 Second-Trimester Doppler Velocimetry of the Uteroplacental Circulation for the Prediction of Fetal Growth Restriction and Pre-eclampsia
19.7 Protocol for Recording the Uterine Artery Doppler in the Second Trimester
19.8 Second-Trimester-Combined Screening Algorithms for Fetal Growth Restriction and Pre-eclampsia
19.9 Third-Trimester-Combined Screening Algorithms for Fetal Growth Restriction and Pre-eclampsia
19.10 Longitudinal Screening for Changes in Doppler Velocimetry of the Uteroplacental Circulation for the Prediction of Fetal Growth Restriction and Pre-eclampsia
19.11 Limitations of Doppler Velocimetry of the Uteroplacental Circulation
19.12 Effect of Low-Dose Aspirin on the Uteroplacental Circulation during Pregnancy in Women at a Risk of Developing Pre-eclampsia
19.12.1 Pharmacology in Pre-eclampsia
19.13 Conclusions
References
20: Uterine Doppler Velocimetry and Hypertensive Disease
20.1 Introduction
20.2 Technical Considerations
20.3 Role of Uterine Artery Velocimetry in the Prediction of Hypertensive Disorders of Pregnancy
20.4 Role of Uterine Artery Velocimetry in the Prediction of Hypertensive Disorders of Pregnancy in Low- and High-Risk Women
20.5 Role of Doppler Velocimetry of the Uterine Arteries in the Prediction of Early-Onset vs Late-Onset Pre-eclampsia
20.6 Role of Doppler Velocimetry of the Uterine Arteries in the First and Second Trimesters
20.7 Longitudinal Changes in Uterine Artery Doppler Indices
20.8 Role of Uterine Artery Doppler in the Management of Hypertensive Disorders of Pregnancy
20.9 Insights into the Dual Etiology of Pre-eclampsia: Role of the Assessment of Uterine Artery Doppler
References
21: Fetal Doppler Velocimetry in Monochorionic Pregnancy: Twin Reversed Arterial Perfusion, Twin-to-Twin Transfusion Syndrome, and Twin Anemia Polycythemia Sequence
21.1 Twin Pregnancies
21.1.1 Diagnosis of Dichorionic Versus Monochorionic Pregnancies
21.1.2 Vascular Anastomoses
21.2 Adverse Outcomes in Monochorionic Pregnancies
21.2.1 Growth Discordance
21.2.2 Twin-to-Twin Transfusion Syndrome
21.2.3 Twin Anemia Polycythemia Sequence
21.2.4 Twin Reversed Arterial Perfusion Sequence
21.2.5 Other Complications
21.3 Imaging Modalities Used in the Assessment of Monochorionic Pregnancies
21.3.1 Doppler Velocimetry
21.3.1.1 Umbilical Artery Doppler
21.3.1.2 Middle Cerebral Artery Doppler
21.3.1.3 Ductus Venosus Doppler
21.3.1.4 Umbilical Vein Doppler
21.3.1.5 The Umbilical Arterial-Venous Index
21.3.2 Placental Anastomosis Mapping
21.3.2.1 Two-Dimensional (2D) Ultrasound Mapping
Arteriovenous Anastomoses
Arterio-Arterial Anastomoses
Venovenous Anastomoses
21.3.2.2 3D Mapping
21.3.2.3 MRI Mapping
21.3.3 Intra-cardiac Doppler
21.3.3.1 Fetal Cardiovascular Hemodynamics in TTTS
21.3.3.2 The Recipient
Functional Pulmonary Atresia/Stenosis
Myocardial Performance (Tei) Index (MPI)
Assessment of Myocardial Deformation
Speckle Tracking
Spectral Tissue Doppler Imaging
Aortic Fractional Area Change (AFAC)
The Aortic Isthmus Systolic Index (ISI)
21.3.3.3 The Donor
21.3.3.4 Assessment of Post-laser Ablation
References
22: Doppler Sonography in Pregnancies Complicated by Pre-gestational Diabetes Mellitus
22.1 Introduction
22.2 Maternal Glycemic State and Fetal Hemodynamics
22.2.1 Hyperglycemia and Fetal Hemodynamics
22.2.2 Hypoglycemia and Fetal Hemodynamics
22.3 Umbilical Artery Doppler Sonography in Diabetic Pregnancies
22.3.1 Umbilical Artery Doppler and Perinatal Outcomes
22.3.2 Umbilical Arterial Doppler Sonography and Maternal Glycemic Control
22.4 Doppler Sonography of Other Fetal and Uterine Circulations in Pre-Gestational Diabetic Pregnancies
22.4.1 Fetal Middle Cerebral Artery Doppler
22.4.2 Doppler Analysis of the Fetal Venous System
22.4.3 Fetal Cardiac Doppler
22.4.4 Uterine Artery Doppler
22.4.5 Doppler Analysis of Placental Vascularization
22.5 Clinical Effectiveness and Guidelines
22.6 Conclusions
References
23: Doppler Velocimetry in Prolonged Pregnancy
23.1 Introduction
23.2 Other Vessels
23.2.1 Aortic Blood Flow Doppler
23.2.2 Pulmonary Artery Doppler
23.2.3 Renal Artery Doppler
23.2.4 Uterine Artery Doppler
23.3 Umbilical and Middle Cerebral Artery Doppler
23.4 Conclusions
References
24: Umbilical Artery Doppler for Fetal Surveillance: Diagnostic Efficacy
24.1 Introduction
24.2 Diagnostic Efficacy in High-Risk Pregnancies
24.3 Umbilical Artery Doppler, Non-Stress Test, and Biophysical Profile: Comparative Efficacy
24.4 Fetal Asphyxia and Umbilical Doppler Indices
24.5 Fetal Doppler Sonography and Neurodevelopmental Outcome
24.6 Efficacy of Doppler Sonography for Screening Low-Risk and Unselected Pregnancies
References
25: Absent End-Diastolic Velocity in the Umbilical Artery and Its Clinical Significance
25.1 Introduction
25.2 Incidence
25.3 Technical Considerations
25.4 Absent End-Diastolic Velocity and Its Adverse Consequences
25.5 Perinatal Mortality
25.6 Perinatal Morbidity
25.7 Congenital Malformations and Chromosomal Abnormalities
25.8 Fetal Growth Restriction
25.9 Fetal Asphyxia and Hypoxemia
25.10 Cerebral Hemorrhage
25.11 Necrotizing Enterocolitis
25.12 Hematological Changes
25.13 Hypoglycemia
25.14 Neurodevelopmental Sequelae
25.15 Maternal Hypertension and Absent End-Diastolic Velocity
25.16 Reappearance of End-Diastolic Velocity
25.17 Sequence of Changes in Fetal Surveillance Parameters with Progressive Antepartum Fetal Compromise
References
26: Fetal Doppler Velocimetry in High-Risk Pregnancies: Randomized Clinical Trials
26.1 Introduction
26.2 Trials of Umbilical Artery Doppler in High-Risk Pregnancies
26.2.1 Evidence from Randomized Studies
26.2.2 Implication for Practice
26.3 Trials of Ductus Venosus Doppler in High-Risk Pregnancies
26.3.1 Evidence from Randomized Studies
26.3.2 Implication for Practice
26.4 Trials of Middle Cerebral Artery Doppler or its Ratio to the Umbilical Artery in High-Risk Pregnancies
26.4.1 Evidence from Randomized Studies
26.4.2 Implication for Practice
26.5 Implications for Research
References
27: Doppler Interrogation of the Umbilical Venous Flow
27.1 Introduction
27.2 Fetal Flow Volume Measurements in the Era of Digital Computing and Imaging
27.2.1 Sources of Inaccuracies
27.2.2 Source of Accuracy
27.2.3 Volume Flow Values and Problems of Standardization
27.2.4 Comparison Between Non-invasive Doppler Volume Flow Values and Experimental Research
27.3 The Relationship of Umbilical Vein Blood Flow with Growth in the Human Fetus
27.4 Clinical Value of Umbilical Vein Blood Flow in Severe Fetal Growth Restriction
27.5 Diagnostic Usage of Umbilical Vein Blood Flow in Late Growth Restriction and in “Constitutionally Small Fetuses”
References
28: The Ductus Venosus
28.1 Historical Background
28.2 Functional Anatomy
28.3 Hemodynamic Background
28.3.1 Via Sinistra and Via Dextra
28.3.2 The Distributional Unit Ductus Venosus–Foramen Ovale
28.3.3 Distribution to the Ductus Venosus or Liver Perfusion
28.3.4 The Umbilicocaval (Portosystemic) Pressure Gradient
28.3.5 Abdominal–Thoracic Pressure Difference
28.3.6 Ultrasound Gray-Scale Imaging
28.3.7 Color Doppler Imaging
28.3.8 Pulsed Wave Doppler Recording
28.3.9 Normal Ductus Venosus Blood Velocity
28.3.10 Waveform Analysis
28.3.11 Interpretation of the Waveform: A-Wave
28.3.12 A-Wave in Early Pregnancy
28.3.13 Interpretation of the Systolic Wave
28.4 Pitfalls
28.5 Reproducibility
28.6 Agenesis of the Ductus Venosus
28.7 Immediate Postnatal Development
References
29: Doppler Examination of the Fetal Pulmonary Venous Circulation
29.1 Introduction
29.1.1 Pulmonary Venous Anatomy and Embryology
29.1.2 Fetal Pulmonary Vein Physiology
29.2 Approach to Imaging of the Pulmonary Veins
29.2.1 2D Assessment
29.2.2 Color Doppler Assessment
29.2.3 Pulsed Wave (PW) Doppler Assessment
29.2.4 Power Doppler and Microflow Imaging Modalities
29.2.5 3D and 4D Fetal Pulmonary Vein Imaging with STIC, TUI, and B-Flow
29.3 Congenital Anomalies of the Pulmonary Venous System
29.3.1 Total Anomalous Pulmonary Venous Return (TAPVR)
29.3.1.1 Supracardiac TAPVR
29.3.1.2 Intracardiac TAPVR
29.3.1.3 Infracardiac TAPVR
29.3.1.4 Mixed TAPVR
29.3.2 Partial Anomalous Pulmonary Venous Return (PAPVR)
29.3.2.1 PAPVR with Sinus Venosus Atrial Septal Defect
29.3.2.2 PAPVR in Scimitar Syndrome
29.3.2.3 PAPVR of the Left Pulmonary Veins
29.3.3 Other Rare Pulmonary Venous Anomalies
29.3.3.1 Cor Triatriatum Sinister
29.4 Utility of Pulmonary Venous Doppler in Setting of Cardiac Disease
29.5 Role for PV Doppler in Diagnosis of Fetal Arrhythmia
29.6 Role for Prenatal Diagnosis Improving Perinatal Management
29.7 Summary
References
30: Introduction to Fetal Doppler Echocardiography
30.1 Introduction
30.2 General Considerations
30.3 Choice of Equipment for Doppler Echocardiography
30.4 Doppler Modalities for Fetal Echocardiography
30.4.1 Fetal Cardiac Color Doppler
30.4.2 Fetal Cardiac Spectral Doppler
30.4.3 Fetal Cardiac M-Mode
30.4.4 Fetal Cardiac Tissue Doppler
30.5 Indications for Fetal Echocardiography
30.6 Method of Fetal Doppler Echocardiography
30.7 Doppler Assessment of Fetal Cardiac Hemodynamics
30.7.1 Atrial Flow
30.7.2 Atrioventricular: Tricuspid and Mitral Flow
30.7.3 Ventricular Outflows: Pulmonary Artery and Aorta
30.7.4 Doppler Determination of Myocardial Performance Index
30.7.5 Doppler Determination of Fetal Cardiac Output
30.7.6 Cardiac Output: Normative Data
30.7.7 Right Heart Versus Left Heart Dominance
30.7.8 Limitations of Cardiac Output Measurement
30.8 Doppler Echocardiography During Early Pregnancy
References
31: Fetal Echocardiography to Plan Postnatal Management in Fetuses with Congenital Heart Disease
31.1 Introduction
31.2 Fetal Circulation/Doppler Assessment Under Normal Conditions and in the Presence of CHD
31.3 Doppler in Fetal Echocardiography to Risk Stratify and Plan Postnatal Management
31.4 Low-Risk CHD
31.4.1 Shunt Lesions
31.4.2 Valve Abnormalities
31.5 Minimal-Risk CHD
31.5.1 Pulmonary Obstruction
31.5.1.1 Systemic Outflow Obstruction
31.6 High-Risk CHD
31.6.1 CHD Dependent on FO Patency
31.6.2 CHD Resulting in Diminished Systemic Perfusion
References
32: Doppler Echocardiography of Fetal Cardiac Arrhythmias
32.1 Introduction
32.2 Methods and Techniques of Fetal Cardiac Activity Assessment
32.3 Fetal Arrhythmias
32.4 Bradyarrhythmia
32.5 Tachyarrhythmias
References
33: 4D Fetal Doppler Echocardiography
33.1 Introduction
33.2 Historical Perspective of Spatiotemporal Imaging Technology (STIC) and the Incorporation of Color and Power Doppler Imaging Modalities
33.3 Newer Applications of Color and Power Doppler STIC Technology
33.3.1 First Trimester Rendered Images of the Cardiovascular System
33.3.2 Second and Third Trimester Identification of Complicated Arch Anomalies and Pulmonary Veins
33.3.3 Second and Third Trimester Identification of the Location of Ventricular Septal Defects
33.4 Benefits of STIC Color and Power Image Acquisition
References
34: Cardiac Function in Fetal Growth Restriction
34.1 Introduction
34.2 Early FGR
34.3 Late Fetal Growth Restriction
References
35: Role of Ultrasonography in Placenta Accreta Spectrum
35.1 Introduction, Epidemiology and Risk Factors
35.2 Clinical Implications
35.3 Ultrasound Findings
35.4 Color Doppler Ultrasound
35.5 3D and Power Doppler Imaging
35.6 Technical Aspects [16]
35.6.1 Bladder Volume [25]
35.6.2 Angle of Insonation
35.6.3 Transabdominal and Transvaginal Probe Pressure
35.6.4 Color Doppler and (3D) Power Doppler
35.7 Clinical Examples
35.7.1 Clinical Cases-Imaging-Related to Clinical Findings During Surgery
References
36: Three-Dimensional Doppler Ultrasound in Gynecology
36.1 Technique
36.2 3D Doppler Measurements
36.3 3D Doppler in Human Reproduction
36.4 3D Doppler in Gynecologic Oncology
36.5 3D Doppler in Benign Gynecology
36.6 Conclusion
References
37: Doppler Ultrasound in Early Pregnancy Including Miscarriage, Ectopic Pregnancy, and Implantation
37.1 Introduction
37.1.1 Types of Doppler and Their Application in Early Pregnancy
37.1.2 Normal Pelvic Blood Flow During the Ovulation, Luteal Phase, Implantation, and Early Pregnancy: General Concepts
37.2 Early Pregnancy States: Definitions
37.3 Role of Doppler Ultrasound in the Diagnosis of Intrauterine Viable Pregnancies
37.4 Role of Doppler Ultrasound in the Diagnosis of Intra-cavitary Retained Products of Conception (RPOC)
37.5 Role of Doppler Ultrasound in the Diagnosis of Ectopic Pregnancies
37.6 Role of Doppler Ultrasound in the Diagnosis of Gestational Trophoblastic Disease
37.7 Safety of Ultrasound During Early Pregnancy
37.8 Conclusions
References
38: Doppler in Benign and Malignant Conditions of the Ovary
38.1 Introduction
38.2 The Normal Ovary and Its Circulation
38.3 Effect of Pathology on the Ovarian Circulation
38.4 Role of Ultrasound and Doppler in the Assessment of Ovarian Tumors
38.4.1 Pulsed Doppler
38.4.2 Color Doppler
38.4.3 Other Methods
38.5 Role of Ovarian Doppler in Early Pregnancy
38.5.1 The Corpus Luteum
38.5.2 Ovarian Ectopic Pregnancy
38.5.3 Decidualized Endometrioma
38.6 Other Conditions Affecting the Ovary
38.6.1 Ovarian Torsion
38.6.2 Pelvic Inflammatory Disease
38.7 Non-ovarian Pathology
38.7.1 Pedunculated Fibroid
38.7.2 Peritoneal Pseudocysts
38.7.3 Pelvic Kidney
38.8 Conclusion
References
39: Doppler in Benign and Malignant Conditions of the Uterus
39.1 Introduction
39.2 Myometrium and Myometrial Lesions
39.2.1 Normal Myometrium
39.2.2 Benign Lesions
39.2.2.1 Fibroids
39.2.2.2 Adenomyosis
39.2.3 Malignant Lesions
39.3 Endometrium and Intracavitary Lesions
39.3.1 Physiological Changes
39.3.2 Benign Lesions
39.3.2.1 Endometrial Polyps
39.3.2.2 Intracavitary Fibroids
39.3.2.3 Retained Products of Conception (RPOC)
39.3.3 Malignant Lesions
39.3.3.1 Endometrial Cancer
39.4 Miscellaneous
References