Utility of uterine artery Doppler
and pulsatility index at 11-14 weeks of normal pregnancy in prediction
of preeclampsia in third trimester
Jyoti Bindal 1,Niketa Chugh 2
1Dr Jyoti Bindal Professor & Head, Department of
Obstetrics & Gynaecology, 2Dr Niketa Chugh, Ex
Resident, Department of Obstetrics & Gynaecology.
Both affiliated with G R Medical College, Gwalior, MP, India.
Address for Correspondece:
Dr Jyoti Bindal, JAH Campus, G R Medical College, Gwalior, MP, India.
drjyotibindal@bindal.me
Abstract
Introduction:
Preeclampsia affects 5-8% of women in pregnancy and leading cause of
maternal mortality. The present study was done to predict the
development of preeclampsia in patients with uterine artery pulsatility
index (PI) >1.71 and the presence of diastolic notch at 11-14
weeks of gestation belonging to low risk population. Methods: Women
attending routine antenatal care were offered an early transvaginal
ultrasound scan between 11-14 weeks including uterine artery doppler
assessment. Mean PI and presence or absence of bilateral early
diastolic notch was also noted. All patients were followed up to term
for the development of preeclampsia. Results: Out of 100
patients, 22% developed preeclampsia of which 15 (68.18%) cases showed
the presence of diastolic notch and 12 (54.54%) cases had PI
>1.71 (p<0.05). A Total of 12% of patients showed
presence of both diastolic notch and PI of >1.71
(p<0.05). Out of 37 nulliparous patients 13 (35.13%) developed
preeclampsia, 8 (13.79%) out of 58 primiparous and 1 (20%) out of 5
multipara developed preeclampsia (p<0.05). All 11 patients with
systolic blood pressure >140mm of Hg at 11-14 weeks of gestation
developed preeclampsia (p<0.05). Conclusion: Presence
of diastolic notch and PI of >1.71 in uterine artery colour
doppler at 11-14 weeks of gestation serves as a good predictor of
preeclampsia at term, in pregnancies with no other associated risk
factors.
Key Words: Pulsatility
index, Preeclampsia, Diastolic notch
Manuscript received: 7th
Feb 2016, Reviewed: 15th
Feb 2016
Author Corrected: 25th
Feb 2016, Accepted for
Publication: 13th March 2016
Introduction
Hypertensive disorders and their associated complications are
responsible for a significant proportion of perinatal and maternal
morbidity and mortality during pregnancy. Although the exact aetiology
of this range of disorders is unknown and very likely multi-factorial,
several lines of evidence suggest a common base in abnormal
placentation and impaired perfusion in all [1].
Indeed there is extensive evidence that uterine artery Doppler
ultrasound constitutes a useful non-invasive method to assess
utero-placental perfusion and to predict further development of
preeclampsia, fetal growth restriction, placental abruption and
stillbirth [2].
There is some evidence that the identification of at risk population in
the first and early second trimesters of pregnancy would allow the
investigation of the possible effects of different prophylactic
strategies [3].
Diastolic notch is small dip (usually found during 12-14 weeks of
gestation) found just before the diastolic wave begins. It suggests
that process is ongoing [4].
The majority of research has been cantered on an elevation in the
pulsatility index or the persistence of a uterine artery diastolic
notch to detect the presence of increased utero-placental vascular
resistance [4].
It has been suggested by many studies that uterine artery Doppler at
12-16 weeks of gestation are very useful to identifying risk of
pre-eclampsia [3,5]. One study evaluated its utility in third-trimester
to predict hemodynamic deterioration and adverse perinatal outcome [6].
The Gomez et al evaluated the uterine artery PI value in the first
trimester and were able to identify 30.8% of pregnancies that
subsequently developed severe pregnancy complications by using the 90th
percentile as the cut-off [7].
In the present study, uterine artery colour doppler and PI values along
with presence of diastolic notch was studied at 11-14 weeks of
gestation in normal pregnancy and assessed as a predictor of
preeclampsia at term.
Method
A hospital based prospective study was carried out on 100 patients at
the Department of Obstetrics and Gyneacology, Kamla Raja Hospital,
Gwalior over a period of one year from November 2013 to October
2014. A written informed consent from all the patients and
Ethical Committee approval was obtained before starting the study.
All women attending routine antenatal care with a singleton pregnancy
at 11-14 weeks of gestation were included in the present study.
Patients with history of essential hypertension, history of
preeclampsia in previous pregnancy, history of treatment with aspirin
and heparin or anti-hypertensive drugs were excluded from the study.
All patients underwent an early transvaginal ultrasound including
uterine artery Doppler and PI values of both uterine arteries were
calculated. The presence or absence of early diastolic notch was also
noted. These patients were followed up to the term for development of
preeclampsia.
All the data were analyzed using IBM SPSS- ver.20 software. Analysis
was performed using chi-square test and independent sample student t
test. P values <0.05 was considered to be significant.
Result
Out of 100 patients, most of the patients belong to the age group of
21-30 (52%) years, about half of the patients had secondary education
(49%), and belong to socioeconomic status class 3(45%), most of them
were having single parity (58%) and maximum patients had gestational
age of more than 38 weeks (Table 1).
Table-1: Distribution of
patients according to different characteristic of patients
|
Parameters
|
No
of Patients
|
Preeclampsia*
|
Non-Preeclampsia*
|
|
Age
(years)#
|
≤20
|
46
|
11
(23.9)
|
35
(76)
|
|
21-30
|
52
|
10
(19.2)
|
42
( (80)
|
|
>30
|
2
|
1
(50)
|
1
(50)
|
|
Education@
|
Primary
|
11
|
1
(9)
|
10
(90.9)
|
|
Secondary
|
49
|
17
(34.6)
|
32
(65.3)
|
|
Intermediate
|
38
|
4
(10.5)
|
34
(89.4)
|
|
Graduation
|
2
|
0(0)
|
2
(100)
|
|
Socioeconomic
Status#
|
2
|
3
|
0(0)
|
3(100)
|
|
3
|
45
|
9
(20)
|
36
(80)
|
|
4
|
32
|
8
(25)
|
24
(75)
|
|
5
|
20
|
5
(25)
|
15
(75)
|
|
Parity@
|
0
|
37
|
13
(35.2)
|
24
(64.8)
|
|
1
|
58
|
8
( 13.7)
|
50
(86.2)
|
|
2
|
5
|
1
(20)
|
4
(80)
|
|
Gestational
age (weeks)
|
>38
|
62
|
2
(3.2)
|
60
(96.7)
|
|
36-38
|
28
|
14
(50)
|
14
(50)
|
|
34-36
|
4
|
4
(100)
|
0
(0)
|
|
32-34
|
5
|
2
(40)
|
3
(60)
|
BP at 11 -14 weeks of gestation showed that 83% had SBP of
<130 mm Hg, out of which 6 (7.22%) developed preeclampsia, 6%
patients had SBP between 130-139 mm Hg, out of which 5 (83.3%) had
developed preeclampsia and all 5% patients who had SBP >150 mmHg
developed preeclampsia (p=0.001). All 22% patients who had diastolic
blood pressure between 90-100 mm Hg during 11-14 weeks of gestation
developed preeclampsia. Out of 35 patients, who had diastolic notching
at 11-14 weeks, 15 (42.8%) patients had preeclampsia, whereas out of 65
patients who had no diastolic notch at 11-14 weeks of gestation,
preeclampsia was noted in 7 (10.7%) patients (p<0.05).
Patients developing preeclampsia (12 cases) were found to have
pulsatility index >1.71 making the association statistically
significant. (p=0.001)
In presence of diastolic notch, 57.14% patients who developed
preeclampsia had pulsatility index >1.71 while 22.22% patients
who developed preeclampsia had pulsatility index <1.71, hence
making the association statistically significant (p=0.027).
Discussion
We tried to find, whether uterine artery Doppler measurements made
between 11-14 weeks of gestation would predict the subsequent
development of preeclampsia.
Out of 100 women studied 22 % developed preeclampsia making the
prevalence almost similar to previous studies (31.42 %) [8].
In present study, there was no association between preeclampsia and the
age of women (p=0.536). Similar results were reported by Kiondo et al
(p=0.33) [9].
Most of the patients (49%) had secondary education, of which, 17
(34.69%) had preeclampsia and no patients was graduate. In present
study there was a significant association between educational status
and development of preeclampsia (p=0.027). Dinglas et al has also
reported significant relationship between education level and
development of signs and symptoms of preeclampsia (Χ²
=9.059, p value=0.018) [10]. Mothers with no education were about seven
times more likely to have all six signs and symptoms of preeclampsia
than those with seven or more years of education [10]. Kiondo et al
showed discordant results where he found no such relation between
patient’s education and development of preeclampsia (p=0.135)
[9].
Most of the patients (45%) belong to socioeconomic class 3 as per the
Modified B.G. Prasad classification [11]. Out of that, 9 (20%) patients
developed preeclampsia. None of the patients belonging to socioeconomic
class 2 developed preeclampsia. There was no correlation between
socioeconomic class and development of preeclampsia (p=0.747) Similar
findings has been reported by other workers also [9]. Lindsay et al in
their study however found that low maternal socioeconomic status was a
strong risk factor for development of preeclampsia [12].
Out of 37 nulliparous patients, 13 (35.13%) developed preeclampsia
which was significant (p<0.05). Out of 58 primiparous patients,
8 (13.79%) developed preeclampsia (p=0.04). Similar results were seen
in study by Long et al, they reported preeclampsia incidence of 9.3%,
being significantly higher in primipara (14.1%) than multipara
(5.7%)(p<0.001) [13]. Kiondo et al also reported that
primigravidae were three times more likely to develop pre-eclampsia
than women who were gravida 2–4 (p<0.001) [9].
Six (7.22%) patients with SBP <130 mmHg developed preeclampsia
whereas every patients with SBP more than 150 mmHg developed
preeclampsia (p<0.05). Almost similar results were reported by
other study [9].
Out of 100 patients, 35% developed diastolic notch at 11-14 weeks of
gestation, of that 15 (42.8%) developed preeclampsia (p=0.002), which
is similar to Gupta et al who reported 31.42% patients developing
preeclampsia in presence of diastolic notching [8]. This is less as
compared to Myatt et al wherein 15% cases had presence of diastolic
notching at <21 weeks of gestation and 18% of these patients
developed preeclampsia [14]. Present study, as 35% had diastolic
notching at 11 –14 weeks of pregnancy out of that 15 (42.85%)
developed preeclampsia, hence sensitivity of diastolic notching is 68
%, specificity is 74 %, positive (PPV) and negative predictive values
(NPV) were 42.85 % and 89.23 % respectively in prediction of
preeclampsia.
In present study, the mean PI was 1.179 at 11-14 weeks of gestation.
But in patients with preeclampsia mean PI value at 11-14 weeks was 1.44
which was significant compared to non-preeclamptic women
(p<0.001). This shows that PI can help in prediction of
preeclampsia when combined with uterine artery notching similar to
Gomez et al [7]. Myatt et al also found significant association between
PI and development of preeclampsia, mean PI was 1.10 in women with
preeclampsia while it was 0.98 in women without preeclampsia (p=0.02)
[14]. Out of 100 patients, 15% had PI of >1.71 at 11-14 weeks of
pregnancy out of that 12 (80%) developed preeclampsia hence sensitivity
of PI is 54.54 % and specificity is 96.15%, PPV 85 %, NPV 88 % in
prediction of preeclampsia.
Rattanapuntamamnee et al determined the uterine artery pulsatility
index to describe the characteristic of uterine artery doppler
velocimetry in pregnant Thai patients at 11-13 gestational weeks. They
found that when segregated for gestational age, uterine artery PI was
1.78±0.41 at 11 weeks, 1.72±0.41 at 12 weeks and
1.66±0.43 at 13 weeks gestation. The uterine artery PI was
1.84±0.37 with the presence of notching and was
1.59±0.43 without notching. The uterine artery notching was
present in 19.3%, 16% and 18% of the patients at 11, 12, 13 weeks
respectively. This group found that even in first trimester uterine
artery diastolic notch in combination with other parameters seems to be
a good test for prediction of obstetric vasculopathies especially
pregnancy-induced hypertension (PIH) and intrauterine growth
restriction (IUGR) [5].
Pilalis et al in their study showed that uterine artery doppler
assessed for PI and presence of diastolic notch at 11-14 weeks of
gestation identified one third of subjects with severe early onset
preeclampsia [15]. Similarly when presence of uterine artery diastolic
notch was considered together with pulsatility index >1.71, the
sensitivity was found to be 75%, specificity 60.8 %, PPV 57.14%, NPV
67.78%.
As Desai P mentioned in a review article that disappearance of uterine
artery diastolic notch in combination with other parameters is a good
test for predicting vasculopathies particularly PIH and IUGR in first
trimester, findings of our study also shows that combining PI with
uterine artery notching is helpful in predicting preeclampsia [4].
Conclusion
From the present study we can conclude that use of uterine artery
colour doppler for presence of diastolic notch and measurement of PI
value at 11-14 weeks of gestation is a helpful and non-invasive tool in
prediction of preeclampsia at term in normal pregnancies. The presence
of diastolic notch and PI value >1.71 at 11-14 weeks of
gestation serves as a good predictor of preeclampsia at term in
pregnancies with no other associated risk factors. Hence all
pregnancies should be screened with uterine artery doppler at 11-14
weeks of gestation for identifying cases that could develop
preeclampsia and hence introduce early interventions to prevent and
reduce the severity of the same.
Funding:
Nil, Conflict of
interest: None initiated.
Permission from IRB:
Yes
References
1. Sheppard BL, Bonnar J. An ultrastructural study of utero-placental
spiral arteries in hypertensive and normotensive pregnancy and fetal
growth retardation. Br J Obstet Gynaecol 1981; 88(7):695-05. [PubMed]
2. Harrington K, Cooper D, Lees C, Hecher K, Campbell S. Doppler
ultrasound of the uterine arteries: the importance of bilateral
notching in the prediction of pre-eclampsia, placental abruption or
delivery of a small-for-gestational-age baby. Ultrasound Obstet
Gynecol. 1996 Mar;7(3):182-8. [PubMed]
3. Vainio M, Kujansuu E, Iso-Mustajärvi M,
Mäenpää J. Low dose acetylsalicylic acid in
prevention of pregnancy-induced hypertension and intrauterine growth
retardation in women with bilateral uterine artery notches.
International Journal of Obstetrics and Gynaecology 2002; 109(2):161-7.
4. Desai P. Predicting Obstetric Vasculopathies through Study Diastolic
notch and Other Indices of Resistance to Blood Flow in Uterine Artery.
Int J Infertility Fetal Med 2013; 4 (1):24-30.
5. Rattanapuntamanee O, Uerpairojkit B. Reference range and
characteristic of uterine artery Doppler in pregnant Thai women at
11-13(+6) gestational weeks. J Med Assoc Thai. 2011 Jun;94(6):644-8. [PubMed]
6. Martinez RC, Savchev S, Lemini MC, Mendez A, Gratacos E, Figueras F.
Clinical utility of third-trimester uterine artery Doppler in the
prediction of brain hemodynamic deteriorationand adverse perinatal
outcome in small-for-gestational-age Fetuses. Ultrasound Obstet Gynecol
2015; 45 (3): 273–8.
7. Gómez O, Martínez JM, Figueras F, Del
Río M, Borobio V, Puerto B et al. Uterine artery Doppler at
11-14 weeks of gestation to screen for hypertensive disorders and
associated complications in an unselected population.
Ultrasound Obstet Gynecol 2005; 26(5):490-4.
8. Gupta S, Kumar GP, Preeti B, Anshu K. Transvaginal Doppler
of uteroplacental circulation in early prediction of pre-eclampsia by
observing bilateral uterine artery notch and resistance index at 12-16
weeks of gestation. J Obstet Gynecol India 2009; 59 (6):541-6. [PubMed]
9. Kiondo P, Wamuyu-Maina G, Bimenya GS, Tumwesigye NM, Wandabwa J,
Okong P. Risk factors for pre-eclampsia in Mulago Hospital, Kampala,
Uganda. Trop Med Int Health. 2012 Apr;17(4):480-7. doi:
10.1111/j.1365-3156.2011.02926.x. Epub 2011 Dec 13. [PubMed]
10. Dinglas C, Lardner D, Homchaudhur A , Kelly C, Briggs C, Passafaro
M. Relationship of Reported Clinical Features of Pre-eclampsia and
Postpartum Haemorrhage to Demographic and other Variables. West African
Journal of Medicine. 2011; 30(2): 84–8.
11. Mangal A, Kumar V, Panesar S, Talwar R, Raut D, Singh S. Updated BG
Prasad socioeconomic classification, 2014: a commentary. Indian J
Public Health. 2015 Jan-Mar;59(1):42-4. doi: 10.4103/0019-557X.152859. [PubMed]
12. Silva LM, Coolman M, Steegers EA, Jaddoe VW, Moll HA, Hofman A,
Mackenbach JP, Raat H. Low socioeconomic status is a risk factor for
preeclampsia: the Generation R Study. J Hypertens. 2008
Jun;26(6):1200-8. doi: 10.1097/HJH.0b013e3282fcc36e.
13. Long PA, Abell DA, Beischer NA. Parity and pre-eclampsia. Aust N Z
J Obstet Gynaecol. 1979 Nov;19(4):203-6. [PubMed]
14. Myatt L, Clifton RG, Roberts JM, Spong CY, Hauth JC, Varner MW,
Wapner RJ, Thorp JM Jr, Mercer BM, Grobman WA, Ramin SM, Carpenter MW,
Samuels P,Sciscione A, Harper M, Tolosa JE, Saade G, Sorokin Y,
Anderson GD; Eunice Kennedy Shriver National Institute of Child Health
and Human Development (NICHD) Maternal-Fetal Medicine Units Network
(MFMU). The utility of uterine artery Doppler velocimetry in prediction
of preeclampsia in a low-risk population. Obstet Gynecol. 2012
Oct;120(4):815-22.
15. Pilalis A, Souka AP, Antsaklis P, Daskalakis G, Papantoniou N,
Mesogitis S, Antsaklis A. Screening for pre-eclampsia and fetal growth
restriction by uterine artery Doppler and PAPP-A at 11-14 weeks'
gestation. Ultrasound Obstet Gynecol. 2007 Feb;29(2):135-40.
How to cite this article?
Bindal J, Chugh N, Utility of uterine artery Doppler and pulsatility
index at 11-14 weeks of normal pregnancy in prediction of preeclampsia
in third trimester : Int J Med Res Rev 2016;4(3):432-436. doi:
10.17511/ijmrr.2016.i03.026.