Table 6

Impact of umbilical artery and ductus venosus Doppler velocimetry on stillbirth and perinatal mortality

Source

Location and Type of Study

Intervention

Stillbirths/Perinatal Outcomes


Reviews and meta-analyses


Baschat et al. 2004 [49]

Germany, Netherlands, UK, USA, Spain, Sweden. Review. 8 studies included. N = 320 fetuses with normal Doppler, N = 202 with elevated ductus venosus (DV) Doppler indices (N = 101 with umbilical artery absent or reversed end-diastolic flow (UA A/REDV), N = 34 with DV reversed atrial velocity (DV-RAV).

Assessed association of umbilical artery Doppler and ductus venosus Doppler with perinatal outcome in preterm growth-restricted fetuses.

Perinatal mortality was 5.6% (16/282) with normal DV, 11.9% (12/101) with UA A/REDV, 38.8% (64/165) with abnormal DV and 41.2% (7/17) with DV-RAV


Alfirevic and Neilson 1996 [50]

Australia, Sweden, UK (Chester, Edinburgh), South Africa (Tygerberg), Ireland (Dublin), Netherlands (Maastricht).

Meta-analysis (Cochrane). 11 RCTs included (N = 6753 high-risk pregnant women).

Assessed the effects of Doppler umbilical artery waveform analysis (intervention) vs. no Doppler (controls) on obstetric care and fetal outcomes.

SBR: OR = 0.79 (95% CI: 0.46–1.34) [NS]

[24/3325 vs. 31/3428 in intervention vs. control groups, respectively].

PMR: OR = 0.71 (95% CI: 0.50–1.01) [NS]

[53/3433 vs. 75/3532 in intervention vs. control groups, respectively].


Intervention studies


Baschat et al. 2003 [47]

Germany.

Prospective cohort. N = 224 pregnancies with growth-restricted fetuses <37 weeks gestation.

Used logistic regression to assess the predictive ability of Doppler diagnosis of absent or reversed umbilical artery end-diastolic velocity, absence or reversal of atrial systolic blood flow velocity in the ductus venosus and pulsatile flow in the umbilical vein to predict stillbirth and perinatal mortality.

PMR: Umbilical artery waveform analysis most predictive compared to other Doppler modalities (R2 = 0.49, P < 0.001)

SBR: Umbilical artery waveform analysis most predictive compared to other Doppler modalities(R2 = 0.48, P < 0.001).

In cases of abnormal or reversed end-diastolic umbilical artery flow, venous pulsatility improved prediction of stillbirth.


Giles et al; DAMP Study Group 2003 [52]

Australia, New Zealand, Southeast Asia. Tertiary level referral hospitals.

Multi-centre RCT. Pregnant women (N = 526) with twin pregnancies at 25 wks gestation.

Compared the impact of Doppler ultrasound umbilical artery flow velocity waveform analysis (intervention) vs. no Doppler (controls) on pregnancy outcomes. Standard ultrasound biometric assessment in both arms.

Fetal death (miscarriage + SB): OR = 0.14 (95% CI: 0.01–1.31) [NS]

[0/262 vs. 3/264 in intervention vs. control groups, respectively.

PMR: 9/1000 vs. 11/1000 live births in intervention vs. control groups, respectively [NS]


No authors listed 1997. [171]

France. 20 centres.

Multicentre RCT. Low risk pregnant women (N = 3898) at 28 wks of gestation.

Compared the impact of umbilical Doppler 28–34 wks gestation (intervention) vs. no routine umbilical Doppler except in cases of clinical indication (controls).

SBR: OR = 0.40 (95% CI: 0.04–2.44) [NS]

[2/1948 vs. 5/1943 in intervention vs. control groups, respectively].

PMR: OR = 0.33 (95% CI: 0.06–1.33) [NS]

[3/1948 vs. 9/1943 in intervention vs. control groups, respectively].


Davies et al. 1992 [172]

UK (London). Single centre; unselected population.

RCT. Singleton pregnancies (N = 2600) > 20 wks gestation.

Compared the impact of routine umbilical and uterine artery Doppler ultrasound to assess placental perfusion (intervention) vs. no Doppler (controls) on pregnancy outcomes. Standard ANC in both arms.

SBR: 11/1246 vs. 4/1229 in intervention vs. control groups, respectively.

PMR (uncorrected): RR = 2.4 (95% CI: 1.00–5.76) [NS]

[17/1246 vs. 7/1229 in intervention vs. control groups, respectively].

PMR (normally formed): RR = 3.95 (95% CI: 1.32–11.77).

[16/1246 vs. 4/1229 in intervention vs. control groups, respectively].


Whittle et al. 1994 [173]

UK (Glasgow).

RCT. Singleton pregnancies (N = 2986) < 26 wks gestation at 1st ANC visit. Doppler ultrasound at 26–30 wks and 34–36 wks gestation in all women.

Compared the impact of umbilical artery Doppler ultrasound revealed to clinician (intervention) vs. concealed from clinician (controls).

SBR: OR = 0.34 (95% CI: 0.10–1.07) [NS]

[3 vs. 8 in intervention vs. control groups, respectively.]


Observational studies


Hugo et al. 2007 [48]

South Africa (Cape Town). Secondary hospital.

Case series. Singleton pregnant women (N = 572) referred for suspected poor fetal growth.

Investigated the use of a personal computer- based, continuous-wave Doppler machine by a trained midwife to assess umbilical artery flow velocity waveforms with respect to the resistance indices (RIs).

PMR:

[RIs < P75]: 13.2

[RIs: P75-95]: 39.1

[RIs > P95]: 41.7

SGA (%):

[RIs < P75]: 27.2%

[RIs: P75-95]: 41.2%

[Ris > P95]: 55.6%


Theron et al. 1992 [41]

South Africa.

Prospective cohort study. Pregnant women (N = 127) with poor symphysis fundal growth (N = 39 abnormal Doppler flow velocimetry, N = 88 normal velocimetry).

Compared the impact of poor Doppler flow velocimetry of umbilical artery (exposed) with normal flow (unexposed).

PMR: OR = 33.2 (95% CI: 6.6–109.6; P < 0.000001).

[43.6% vs. 2.3% in exposed vs. unexposed groups, respectively].

Fetal death (miscarriage + SB):

[28.2% vs. 0% in exposed vs. unexposed groups, respectively; (P < 0.0005)].


Torres et al. 1995 [42]

Spain (Barcelona). Hospital Clinic.

Prospective observational study over a 2-year period. Hypertensive pregnant women (N = 172; N = 166 with live births, N = 6 fetal deaths).

Assessed the use of umbilical artery Doppler in predicting SB. Compared the impact of absent (exposed) vs. normal end-diastolic velocity (unexposed).

SB: All had absence of end-diastolic velocity (sensitivity 100%).

Fetal death (miscarriage + SB): 6/9 vs. 0/163 in absent vs. normal flow.

Absent end-diastolic velocity in predicting fetal death: sensitivity: 100%, specificity: 98.2%, positive predictive value 66.7%, negative predictive value 100%.


Haws et al. BMC Pregnancy and Childbirth 2009 9(Suppl 1):S5   doi:10.1186/1471-2393-9-S1-S5

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