Middle cerebral artery to uterine artery pulsatility index ratios in pregnancy with fetal growth restriction regarding negative perinatal outcomes

Doppler indexes in fetal growth restriction

Authors

Keywords:

Fetal growth restriction, Cerebroplacental ratio, Uterine artery pulsatility index, Middle cerebral artery pulsatility index, Doppler

Abstract

Background/Aim: Fetal growth restriction (FGR) causes a high risk of perinatal morbidity and mortality, and the timing of the correct delivery time decision remains controversial. Cerebroplacental ratio (CPR), umbilical artery, uterine artery (UA) and middle cerebral artery (MCA) Doppler studies are used to predict adverse perinatal outcomes in FGR. However, since there is insufficient reliability for each separately and together, the search for new methods continues. This retrospective study was conducted to determine the degree of neonatal morbidity in fetuses suspected of having FGR by evaluating the MCA to UA pulsatility index (PI) ratios together with frequently used Doppler examinations.

Methods: This was a retrospective cohort study conducted in a single-center hospital with the approval of the Medical Institutional Ethics Committee. A total of 424 pregnant women admitted to a tertiary hospital and diagnosed with FGR between July 2020 and December 2021 who were informed and approved were included in the study. Gestational age was confirmed by first trimester sonographic measurements of pregnancy. All pregnant women were examined by Doppler USG and umbilical artery, mean UA, fetal MCA, ductus venosus, CPR (MCA/umbilical artery pulsatility index ratio) and cerebrouterine ratio (MCA/UA) PI values were measured. Negative perinatal outcomes were recorded as blood gas level of the newborn at 7.2 and below, Apgar score of 7 and below at the fifth minute, and needing neonatal intensive care (NICU). Adverse perinatal and postnatal outcomes were recorded and compared with Doppler findings. If there were no signs of a negative perinatal outcome, it was considered a positive outcome. If at least one of the symptoms of adverse perinatal outcomes was present, it was considered a negative outcome

Results: Decreased CPR and decreased MCA to UA PI were significantly and positively associated with an increased likelihood of exhibiting negative perinatal outcomes in pregnancies with FGR (P < 0.001, P < 0.001, respectively). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off value for MCA to uterine artery PI was 1.41 to predict FGR with 57.37% sensitivity and 62.50% specificity (AUC: 0.629; 95% CI: 0.581–0.675). When the CPR cut-off value was taken as 1.2069, the sensitivity was 42.86% and the specificity 83.93% in predicting negative perinatal outcomes in CPR values below this value (P < 0.001).

Conclusion: CPR is the most successful criterion in distinguishing between positive and negative perinatal outcomes. It has been demonstrated that the MCA to uterine artery PI ratio values after CPR can also be used for this distinction. MCA to UA PI ratio sensitivity was higher than CPR and umbilical artery. This situation shows that MCA to uterine artery PI ratio (alone or when evaluated together with PPV and NPV ratios) is a criterion that can be added to other Doppler examinations in predicting negative perinatal outcomes.

Downloads

Download data is not yet available.

Author Biographies

Kadir Atakır, Division of Radiology, Istanbul Health and Technology University Department of Radiology and Medical İmaging Technics, Istanbul, Turkey

Division of Radiology ,Istanbul Health and Technology University Department of Radiology and Medical İmaging Technics, Istanbul

Savaş Özdemir, Department of Obstetrics and Gynecology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul, Turkey

Department of Obstetrics and Gynecology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul

Merve Konal, Department of Obstetrics and Gynecology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul, Turkey

Department of Obstetrics and Gynecology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul

Veli Mihmanlı, Department of Obstetrics and Gynecology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul, Turkey

Department of Obstetrics and Gynecology, Prof. Dr. Cemil Taşçıoğlu City Hospital, Istanbul

References

Miller SL, Huppi PS, Mallard C. The consequences of fetal growth restriction on brain structure and neurodevelopmental outcome. J Physiol. 2016 Feb 15;594(4):807-23. doi: 10.1113/JP271402. Epub 2016 Jan 5. PMID: 26607046. DOI: https://doi.org/10.1113/JP271402

ACOG Practice Bulletin No. 204: Fetal Growth Restriction. Obstet Gynecol. 2019 Feb;133(2):e97-e109. doi: 10.1097/AOG.0000000000003070. PMID: 30681542. DOI: https://doi.org/10.1097/AOG.0000000000003070

Froen JF, Gardosi JO, Thurmann A, Francis A, Stray-Pedersen B. Restricted fetal growth in sudden intrauterine unexplained death. Acta Obstet Gynecol Scand. 2004 Sep;83(9):801-7. doi: 10.1111/j.0001-6349.2004.00602.x. PMID: 15315590. DOI: https://doi.org/10.1080/j.0001-6349.2004.00602.x

Monteith C, Flood K, Mullers S, Unterscheider J, Breathnach F, Daly S, et al. Evaluation of normalization of cerebro-placental ratio as a potential predictor for adverse outcome in SGA fetuses. Am J Obstet Gynecol. 2017 Mar;216(3):285.e1-285.e6. doi: 10.1016/j.ajog.2016.11.1008. Epub 2016 Nov 11. PMID: 27840142.

Rial-Crestelo M, Martinez-Portilla R, Cancemi A, Caradeux J, Fernandez L, Peguero A, et al. Added value of cerebro-placental ratio and uterine artery Doppler at routine third trimester screening as a pre- dictor of SGA and FGR in non-selected pregnancies. J Matern Fetal Neonatal Med. 2019 Aug;32(15):2554-60. doi: 10.1080/14767058.2018.1441281. Epub 2018 Mar 4. PMID: 29447050.

Ebbing C, Rasmussen S, Godfrey K, Hanson M, Kiserud T. Fetal celiac and splenic artery flow velocity and pulsatility index: longitudinal reference ranges and evidence for vasodilation at a low porto-caval pressure gradient. Ultrasound Obstet Gynecol. 2008 Oct;32(5):663-72. doi: 10.1002/uog.6145. PMID: 18816500. DOI: https://doi.org/10.1002/uog.6145

Devore GR. 2015. The importance of the cerebroplacental ratio in the evaluation of fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol. 2015 Jul;213(1):5-15. doi: 10.1016/j.ajog.2015.05.024. PMID: 26113227. DOI: https://doi.org/10.1016/j.ajog.2015.05.024

Ciobanu A, Wright A, Syngelaki A, Wright D, Akolekar R, Nicolaides KH. 2019. Fetal Medicine Foundation reference ranges for umbilical artery and middle cerebral artery pulsatility index and cerebroplacental ratio. Ultrasound Obstet Gynecol. 2019 Apr;53(4):465-72. doi: 10.1002/uog.20157. Epub 2019 Feb 13. PMID: 30353583. DOI: https://doi.org/10.1002/uog.20157

Lees CC, Stampalija T, Baschat A, da Silva Costa F, Ferrazzi E, Figueras F, et al. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound Obstet Gynecol. 2020 Aug;56(2):298-312. doi: 10.1002/uog.22134. PMID: 32738107. DOI: https://doi.org/10.1002/uog.22134

Kalafat E, Khalil A. 2018. Clinical significance of cerebroplacental ratio. Curr Opin Obstet Gynecol. 2018 Dec;30(6):344-54. doi: 10.1097/GCO.0000000000000490. PMID: 30299319. DOI: https://doi.org/10.1097/GCO.0000000000000490

Akolekar R, Ciobanu A, Zingler E, Syngelaki A, Nicolaides KH. 2019. Routine assessment of cerebroplacental ratio at 35–37 weeks’ gesta- tion in the prediction of adverse perinatal outcome. Am J Obstet Gynecol. 2019 Jul;221(1):65.e1-65.e18. doi: 10.1016/j.ajog.2019.03.002. Epub 2019 Mar 13. PMID: 30878322. DOI: https://doi.org/10.1016/j.ajog.2019.03.002

Bhide A, Acharya G, Bilardo C, Brezinka C, Cafici D, Hernandez-Andrade E, et al. 2013. ISUOG Practice Guidelines: use of Doppler ultrasonography in obstetrics. Ultrasound Obstet Gynecol. 2013 Feb;41(2):233-9. doi: 10.1002/uog.12371. PMID: 23371348. DOI: https://doi.org/10.1002/uog.12371

Hadlock FP, Harrist R, Sharman RS, Deter RL, Park SK. Estimation of fetal weight with the use of head, body, and femur measurements- a prospective study. Am J Obstet Gynecol. 1985 Feb 1;151(3):333-7. doi: 10.1016/0002-9378(85)90298-4.PMID: 3881966. DOI: https://doi.org/10.1016/0002-9378(85)90298-4

Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, et al. Stillbirths: recall to action in high-income countries. Lancet. 2016 Feb 13;387(10019):691-702. doi: 10.1016/S0140-6736(15)01020-X. Epub 2016 Jan 19. PMID: 26794070. DOI: https://doi.org/10.1016/S0140-6736(15)01020-X

Nohuz E, Riviere O, Coste K, Vendittelli F. Prenatal identification of small-for-gestational age and risk of neonatal morbidity and stillbirth. Ultrasound Obstet Gynecol. 2020 May;55(5):621-8. doi: 10.1002/uog.20282. Epub 2020 Apr 6. PMID: 30950117. DOI: https://doi.org/10.1002/uog.20282

Udo DU, Igbinedion BO, Akhigbe A, Enabudosoe E. Assessment of uterine and umbilical arteries Doppler indices in third trimester pregnancy-induced hypertension in UBTH, Benin-city. Niger Med Pract. 2017;71:3-4.

Munikumari T, Vijetha V, Sree Divya NV. Comparison of diagnostic efficacy of umbilical artery and middle cerebral artery waveform with color Doppler study for detection of intrauterine growth restriction fetuses. Int J Contemp Med Surg Radiol. 2017;2:41-6.

Mirza N, Meena V, Garg R, Gupta V, Iqbal R, Meena K, et al. Comparison of non stress test and umbilical artery doppler in high risk pregnancy. Int J Med Sci Educ. 2017;4:131-7.

Oros D, Figueras F, Cruz-Martinez R, Meler E, Munmany M, Gratacos E. Longitudinal changes in uterine, umbilical and fetal cerebral Doppler indices in late-onset small-for-gestational age fetuses. Ultrasound Obstet Gynecol. 2011 Feb;37(2):191-5. doi: 10.1002/uog.7738. Epub 2010 Jul 8. PMID: 20617509. DOI: https://doi.org/10.1002/uog.7738

Acharya G, Ebbing C, Karlsen HO, Kiserud T, Rasmussen S. Sex specific reference ranges of cerebroplacental and umbilicocerebral ratios: longitudinal study. Ultrasound Obstet Gynecol. 2020 Aug;56(2):187-95. doi: 10.1002/uog.21870. PMID: 31503378. DOI: https://doi.org/10.1002/uog.21870

Khalil A, Morales-Rosello J, Khan N, Nath M, Agarwal P, Bhide A, et al. 2017. Is cerebroplacental ratio a marker of impaired fetal growth velocity and adverse pregnancy outcome? Am J Obstet Gynecol. 2017 Jun;216(6):606.e1-606.e10. doi: 10.1016/j.ajog.2017.02.005. Epub 2017 Feb 8. PMID: 28189607. DOI: https://doi.org/10.1016/j.ajog.2017.02.005

Figueras F, Savchev S, Triunfo S, Crovetto F, Gratacos E. An integrated model with classification criteria to predict small for gestational age fetuses at risk of adverse perinatal outcome. Ultrasound Obstet Gynecol. 2015 Mar;45(3):279-85. doi: 10.1002/uog.14714. Epub 2015 Jan 27. PMID: 25358519. DOI: https://doi.org/10.1002/uog.14714

Bonnevier A, Marsal K, Brodszki J, Thuring A, K€allen K. Cerebroplacental ratio as predictor of adverse perinatal outcome in the third trimester. Acta Obstet Gynecol Scand. 2021 Mar;100(3):497-503. doi: 10.1111/aogs.14031. Epub 2020 Nov 4. PMID: 33078387. DOI: https://doi.org/10.1111/aogs.14031

Monteith C, Flood K, Mullers S, Unterscheider J, Breathnach F, Daly S, et al. Evaluation of normalization of cerebro-placental ratio as a potential predictor for adverse outcome in SGA fetuses. Am J Obstet Gynecol. 2017 Mar;216(3):285.e1-285.e6. doi: 10.1016/j.ajog.2016.11.1008. Epub 2016 Nov 11.PMID: 27840142. DOI: https://doi.org/10.1016/j.ajog.2016.11.1008

Rial-Crestelo M, Martinez-Portilla R, Cancemi A, Caradeux J, Fernandez L, Peguero A, et al. Added value of cerebro-placental ratio and uterine artery Doppler at routine third trimester screening as a predictor of SGA and FGR in non-selected pregnancies. J Matern Fetal Neonatal Med. 2019 Aug;32(15):2554-60. doi: 10.1080/14767058.2018.1441281. Epub 2018 Mar 4. PMID: 29447050. DOI: https://doi.org/10.1080/14767058.2018.1441281

Cruz-Martinez R, Savchev S, Cruz-Lemini M, Mendez A, Gratacos E, Figueras F. Clinical utility of third-trimester uterine artery Doppler in the prediction of brain hemodynamic deterioration and adverse perinatal outcome in small-for-gestational-age fetuses. Ultrasound Obstet Gynecol. 2015 Mar;45(3):273-8. doi: 10.1002/uog.14706. Epub 2015 Jan 27. PMID: 25346413. DOI: https://doi.org/10.1002/uog.14706

Figueras F, Gratacos E. Update on the diagnosis and classification of fetal growth restriction and proposal of a stage-based management protocol. Fetal Diagn Ther. 2014;36(2):86-98. doi: 10.1159/000357592. Epub 2014 Jan 23. PMID: 2445781. DOI: https://doi.org/10.1159/000357592

Savchev S, Figueras F, Gratacos E. Survey on the current trends in managing intrauterine growth restriction. Fetal Diagn Ther. 2014;36(2):129-35. doi: 10.1159/000360419. Epub 2014 May 20. PMID: 24852178. DOI: https://doi.org/10.1159/000360419

Zarean E, Shabaninia S. The Assessment of Association between Uterine Artery Pulsatility Index at 30-34 Week’s Gestation and Adverse Perinatal Outcome. Adv Biomed Res. 2018 Jul 20;7:111. doi: 10.4103/abr.abr 112 17. eCollection 2018. PMID: 30123785. DOI: https://doi.org/10.4103/abr.abr_112_17

Eser A, Zulfıkaroglu E, Eserdag S, Kılıc S, Danısman N. Predictive value of middle cerebral artery to uterine artery pulsatility index ratio in preeclampsia. Arch Gynecol Obstet. 2011 Aug;284(2):307-11. doi: 10.1007/s00404-010-1660-5. Epub 2010 Sep 2. PMID: 20811899. DOI: https://doi.org/10.1007/s00404-010-1660-5

Simanaviciute D, Gudmundsson S. Fetal middle cerebral to uterine artery pulsatility index ratios in normal and pre-eclamptic pregnancies. Ultrasound Obstet Gynecol. 2006 Nov;28(6):794-801. doi: 10.1002/uog.3805. PMID: 17029308. DOI: https://doi.org/10.1002/uog.3805

Zhou S, Guo H, Feng D, Han X, Liu H, Li M. Middle Cerebral Artery-to-Uterine Artery Pulsatility Index Ratio and Cerebroplacental Ratio Independently Predict Adverse Perinatal Outcomes in Pregnancies at Term. Ultrasound Med Biol. 2021 Oct;47(10):2903-9. doi: 10.1016/j.ultrasmedbio.2021.06.015. Epub 2021 Jul 27. PMID: 34325960. DOI: https://doi.org/10.1016/j.ultrasmedbio.2021.06.015

Downloads

Published

2022-09-07

Issue

Section

Research Article

How to Cite

1.
Şirinoğlu H, Atakır K, Özdemir S, Konal M, Mihmanlı V. Middle cerebral artery to uterine artery pulsatility index ratios in pregnancy with fetal growth restriction regarding negative perinatal outcomes: Doppler indexes in fetal growth restriction. J Surg Med [Internet]. 2022 Sep. 7 [cited 2024 May 25];6(9):788-91. Available from: https://jsurgmed.com/article/view/7319