Veeresh S A et al.

, RJMS 2021;11(3):160-164

Original article

Colour Doppler Ultrasound Evaluation of Umbilical Artery and Middle

Cerebral Artery in Suspected Intrauterine Growth Restriction Foetuses

Veeresh S Aland1, HM Chakit Kumar2*

1
Associate Professor, 2Resident
Department of Radiodiagnosis, Faculty of Medicine, Khaja Banda Nawaz University, Kalaburagi,
Karnataka - 585104.
*Corresponding author:
Dr. H M Chakit Kumar, 30, Chandrakanth Patil School Campus, S.B.Patil Nagar, University Road,
Kalaburagi-585105. E-mail: chakitvims@gmail.com
Received date: March 3, 2021; Accepted date: May 28, 2021; Published date: June 30, 2021

Abstract
Background and Aims: Intrauterine growth restriction is strongly related to the dynamics of uteroplacental
and fetoplacental circulation and is associated with an increased risk of perinatal mortality, morbidity and
impaired neurodevelopment. A prospective study was performed to establish a role of Umbilical Artery (UA)
and Middle Cerebral Artery (MCA) Doppler ultrasound (USG) in predicting perinatal outcome in clinically
suspected Intrauterine growth restriction (IUGR) pregnancies, and to determine the role of Doppler velocimetry
in clinical management of such pregnancies.
Methods: This prospective observational study was conducted over a period of 17 months (November 2019
- March 2021) and included 50 cases. After a regular obstetric ultrasound evaluation, special importance was
given to measure Doppler parameters such as Pulsatility Indices (PI) of Umbilical Artery and Middle cerebral
Artery. Colour Doppler ultrasound was performed using GE LOGIQ F8 having low frequency curvilinear
transducer. Follow up Doppler studies were performed, if clinically indicated to determine a favourable or a
worsening pattern in the Doppler indices. However, only the results of first doppler ultrasound were considered
for analysis.
Results: The mean gestational age at the first Doppler US examination was 32.91 weeks ± 3.10 weeks. Forty
six percent of the foetuses had at least one abnormal outcome. The mean Foetal Heart Rate (FHR) was 136.32
± 13.5. The mean Estimated Foetal Weight (EFW) observed was 1.81 ± 0.32. Thirty five (70.0%) cases were
Oligohydramnios and 15 (30.0%) cases were with adequate amniotic fluid. Twenty three foetuses had abnormal
perinatal outcome. MCA PI was most sensitive (sensitivity 95.65%), more than both Cerebroplacental
Ratio (MCA/UA) PI (sensitivity 91.3%) and UA PI (sensitivity 91.3%) in predicting any adverse outcome.
Cerebroplacental Ratio (specificity 81.48%) was more specific compared to UA PI (Specificity 66.6%) and
MCA PI (Specificity 63%), with highest diagnostic accuracy (86%), Positive Predictive Value (PPV=80.8%).
However, UA PI 94.4 had highest Negative Predictive Value followed by Cerebroplacental Ratio 91.66% and
MCA PI 90.0.
Conclusions: The Foetal Doppler indices, in particular, ratios that include measurements from umbilical and
middle cerebral artery help in the detection of the IUGR foetuses. Cerebroplacental ratio (MCA/UA) is a
better predictor of abnormal perinatal outcome than MCA PI and UA PI alone.
Keywords: Intrauterine growth restriction (IUGR), MCA PI, UA PI, MCA/UA, Colour doppler

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Introduction
Intrauterine Growth Restriction (IUGR) is a pathological
condition strongly related to the development and
function of the uteroplacental and fetoplacental
circulation and is related with an higher risk of perinatal
mortality, morbidity and impaired neurodevelopment.1
Placental insufficiency most commonly leads to IUGR,
which is an important perinatal complication on the
account of associated high perinatal mortality and
morbidity. It is crucial to identify placental insufficiency
early so that its hazards can be minimized.
Doppler Ultrasonography (USG) allows a better
understanding of the vascular changes and therefore, has
become indispensable aid for feto-maternal supervision
in high-risk pregnancies. It can be attributed with causing
reduction in perinatal mortality and morbidity.1 Our study
was an effort to establish the role of Umbilical Artery
(UA) and Middle Cerebral Artery (MCA) indices on
Doppler US in predicting perinatal outcome in clinically
suspected IUGR pregnancies, and to determine the role
of Doppler velocimetry in clinical management of such
pregnancies.
Material and Methods
This prospective observational study was conducted
over a period of 17 months (November 2019 - March
2021) and included 50 cases. After a regular obstetric
ultrasound evaluation, Doppler parameters such as
Umbilical Artery and Middle cerebral Artery Pulsatility
Indices (PI) were measured. Colour Doppler ultrasound
was performed using machine GE LOGIQ F8 having
low frequency curvilinear transducer. Follow up Doppler
studies were done, if clinically indicated to determine a
favourable or a worsening pattern in the Doppler indices.
However, only the results of first doppler ultrasound
were considered for analysis in our study.
Results
The mean age of pregnant women included in the study
was 24.64 ± 3.05 years, with minimum age of 20 years
and maximum age of 31 years. The mean gestational age
at the first Doppler US examination was 32.91 ± 3.10
weeks; minimum gestational age was 25 weeks and
maximum gestational age 38 weeks. The mean Foetal
Heart Rate (FHR) was 136.32 ± 13.5; the minimum
FHR observed was 108 and maximum 156. The mean
Estimated Foetal Weight (EFW) observed was 1.81 ±
0.32; the minimum EFW was 1.2 and maximum 2.5.
In the present study, 35 (70.0%) cases were Oligohy
dramnios and 15 (30.0%) cases were with adequate
amniotic fluid. Twenty six (52%) mothers had
Veeresh S A et al., RJMS 2021;11(3):160-164
Pregnancy Induced Hypertension, and 17 (34%) had
anaemia. Twenty three (46%) foetuses had at least one
adverse outcome that included six (12%) Intrauterine
Deaths (IUD). Of the six IUDs, four cases had diastolic
flow reversal and two had absent diastolic flow. In all
cases with diastolic flow reversal, IUD of the foetus
occurred within seven days of the diagnosis. Of the
44 live births, 10 neonates were admitted to Neonatal
ICU. Nine neonates had five min Apgar score of under
7 and 12 babies were born by emergency lower segment
caesarean section (LSCS).
There was statistically highly significant difference
in mean MCA PI, UA PI and MCA/UA between
normal and abnormal perinatal outcome (p<0.01) and
(p<0.001). The mean MCA PI was remarkably lower in
the abnormal perinatal outcome as compared to normal
perinatal outcome. The mean UA PI was significantly
higher in the abnormal perinatal outcome as compared
to normal perinatal outcome. The mean MCA PI/UA
PI was significantly lower in the abnormal perinatal
outcome as compared to normal perinatal outcome.
If cerebroplacental ratio is <1, it was considered as
abnormal.2 (Table 1)
Table 1: Comparison of MCA PI, UA PI and MCA/UA
between normal and abnormal perinatal outcome
Abnormal Normal
perinatal perinatal t-test p-value and
Variables
outcome outcome value significance
Mean ± SD Mean ± SD
MCA PI 1.04 ± 0.32 1.52 ± 0.38 t = 4.705 P = 0.000, VHS
UA PI 1.92 ± 0.58 1.12 ± 0.29 t = 6.261 P = 0.000, VHS
MCA/UA 0.60 ± 0.32 1.45 ± 0.57 t = 6.205 P = 0.000, VHS
NS= not significant, S=significant, HS=highly
significant, VHS=very highly significant
The following multiple bar diagram represents
comparison of MCA PI, UA PI and MCA/UA between
normal and abnormal perinatal outcome.
The data of MCA and UA doppler indices obtained from
50 suspected IUGR cases was plotted on the normogram
and scatter diagrams were obtained. The below scatter
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 Veeresh S A et al., RJMS 2021;11(3):160-164

diagrams show correlation between doppler indices and (MCA/UA) had highest diagnostic accuracy (86%)
perinatal outcome. compared to UAPI (78%) and MCA PI (78%) when
considered alone. Cerebroplacental Ratio (MCA/UA)
Scatter diagram showing correlation between
had highest Positive Predictive Value (PPV=80.8%)
gestational ages and MCA PI values among abnormal
compared to UA PI (PPV=70%) and MCA PI
and normal perinatal outcome
(PPV=68.75%) when considered alone. However, UA
PI 94.4 had highest Negative Predictive Value (NPV)
followed by Cerebroplacental Ratio 91.66% and MCA
PI 90.0. (Table 2)
Table 2: Doppler indices
Doppler Diagnostic
Sensitivity Specificity PPV NPV
Index accuracy
MCA 95.7 63.0 78.0 68.8 90.0
UA 91.3 66.6 78.0 70.0 94.4
MCA/UA 91.3 81.48 86.0 80.8 91.6

Doppler ultrasound in a pregnant woman with

Scatter diagram showing correlation between gestational age 28 wks showing decreased MCA PI
gestational ages and UA PI values among abnormal
and normal perinatal outcome

Scatter diagram showing correlation between

gestational ages and MCA/UA values among
abnormal and normal perinatal outcome

Doppler ultrasound in a pregnant woman with

gestational age 28 wks showing increased UA PI

MCA PI was most sensitive (sensitivity 95.65%). It

was more sensitive than either Cerebroplacental Ratio
MCA/UA PI (sensitivity 91.3%) or UA PI (sensitivity
91.3%) in predicting any adverse outcome. However,
Cerebroplacental Ratio (specificity 81.48%) was more Discussion
specific compared to UA PI (Specificity 66.6%) and Doppler velocimetry of uteroplacental, umbilical
MCA PI (Specificity 63%). Cerebroplacental Ratio and foetal vessels have become an established

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method for foetal monitoring in day-to-day obstetric
practice.3 Circulatory changes reflected in foetal Doppler
waveforms can reliably predict adverse perinatal
outcome. Several investigators have highlighted the
utility of doppler ultrasound of umbilical and foetal
vessels for monitoring foetal well-being, IUGR, foetal
anaemia, and perinatal outcomes.4
Gramellini and co-workers concluded that when compared
either to MCA or UA alone, the cerebroplacental Doppler
ratio gave a better predictor of small-for-gestational age
(SGA) newborns and abnormal perinatal outcome.5 In
fact, in predicting those newborns that were SGA, while
MCA and UA had diagnostic accuracy of 54.4% and
65.5% respectively. The cereboplacental ratio was way
ahead and had a diagnostic accuracy of 70%. The results
were more encouraging for detection of adverse perinatal
outcome; while diagnostic accuracy of MCA and UA was
78.8% and 83.3% respectively, the diagnostic accuracy
of cerebral-placental ratio stood much higher at 90%.
Our study confirms with the findings of Gramellini et
al., that rather than using PIs of MCA and UA separately,
better results were obtained when we used MCA/UA PI
Ratio.5
Chan and colleagues studied 71 high-risk foetuses with
weekly UA and MCA Doppler US examinations until
delivery.6 In 15.5% (11 of 71) of foetuses, there was
perinatal mortality or major morbidity. By using the last
Doppler US result for analysis, the UA/MCA resistance
index ratio when compared with the UA systolic-to-
diastolic ratio was more sensitive (75% vs 64%) but less
specific (60% vs 74%).
Results of the present study confirm with those of Chan
et al. that UA Doppler US was a better predictor for
each of the individual adverse outcomes when separate
analyses were performed.6 Sensitivity, specificity, PPV,
NPV of UA PI in predicting adverse perinatal outcome
were 91.3, 66.6, 70, 94.4 respectively in the present
study.
Fong and colleagues studied 293 small–for–gestational
age foetuses with Doppler US of the UA, MCA, and
RA.7 They concluded that the MCA pulsatility index (PI)
when compared with the UA PI and RA PI was more
sensitive (72.4% vs 44.7% and 8.3%), but less specific
(58.1% vs 86.6% and 92.6%) in predicting abnormal
outcome.
Results of the present study confirm with those of Fong et
al. that MCA PI had more sensitivity but low specificity
in predicting abnormal perinatal outcome.7 The present
Veeresh S A et al., RJMS 2021;11(3):160-164
study has not included the doppler of renal artery as that
in Fong KW et al.
The nomograms we utilized for investigation were from
the prospective, observational study by Srikumar and
colleagues.8 The present study revealed that doppler
study in pregnant women with IUGR played an important
role in management and predicting outcome. Along
with doppler indices, mainly cerebroplacental ratio and
pulsatility index, a valuable method for predicting the
perinatal outcome is to measure umbilical artery end
diastolic flow. The mortality rate for cases with absent
end diastolic flow was 29%. The mortality rate of cases
with reversed diastolic flow was very high (100%).
There were six IUDs in whom two had absent diastolic
flow and four cases had reversal of diastolic flow. IUD
occurred within seven days of conclusion in all cases
with reversal of diastolic flow. And all the four cases
were under 32 weeks. The recommendations for future
examination is to include pregnant ladies in second
trimester and to distinguish early IUGR by foetal and
maternal doppler and its early management to reduce the
occurrence of unfavourable perinatal result.
Conclusion
The foetal Doppler indices, in particular, ratios that
include measurements from umbilical and middle
cerebral artery help in the detection of the IUGR
foetuses. In clinically suspected IUGR patients,
cerebroplacental ratio (MCA/UA) is a better predictor
of abnormal perinatal outcome than MCA PI and UA PI
when considered alone. Absent or reversal of diastolic
flow in the umbilical artery indicates grave prognosis
and high foetal mortality.
Conflict of interest
Nil.
Financial support
Nil.
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