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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 17  |  Issue : 3  |  Page : 757-761

Utility of uterine artery doppler indices for prediction of preeclampsia: A narrative review with systematic analysis


1 Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Dermatology, Venereology and Leprosy, Ram Manohar Lohia Hospital, Lucknow, Utter Pradesh, India

Date of Submission08-Nov-2021
Date of Decision16-Jun-2022
Date of Acceptance08-Sep-2022
Date of Web Publication2-Nov-2022

Correspondence Address:
Dr. Rohan Kumar Singh
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_413_21

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  Abstract 


Background: Hypertensive disorders complicating pregnancy are common. Preeclampsia and eclampsia are major causes of maternal morbidity and mortality, particularly in developing countries. With prompt recognition of symptoms and early diagnosis of preeclampsia can lead to improved maternal and neonatal outcomes. Although, numerous tests have been proposed for the prediction of preeclampsia, their results have been inconsistent. So, we focused our research to study the uterine artery doppler for predicting preeclampsia in high-risk women. Methodology: We conducted a search on Google Scholar and PubMed based on Medical Subject Heading terms preeclampsia and uterine artery Doppler ultrasound. The articles between 2016 and 2020 which were in English were taken into consideration. We performed a qualitative interpretation as an approach for extracting the data. Results: Majority of the studies showed raised pulsatility index as a good predictor of preeclampsia, although it was closely followed by uterine artery notching which is in the early diastolic period. Conclusion: The findings of our research suggest that uterine artery Doppler indices and early diastolic notch can be used as a tool for the prediction of preeclampsia with high confidence.

Keywords: Doppler ultrasound, early diastolic notch, preeclampsia, pulsatility index, resistive index, systolic/diastolic ratio, uterine artery


How to cite this article:
Patwa PA, Mishra GV, Dhande RP, Singh RK, Singh S. Utility of uterine artery doppler indices for prediction of preeclampsia: A narrative review with systematic analysis. J Datta Meghe Inst Med Sci Univ 2022;17:757-61

How to cite this URL:
Patwa PA, Mishra GV, Dhande RP, Singh RK, Singh S. Utility of uterine artery doppler indices for prediction of preeclampsia: A narrative review with systematic analysis. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Feb 4];17:757-61. Available from: http://www.journaldmims.com/text.asp?2022/17/3/757/360220




  Introduction Top


Pregnancy is a precious stage in maternal life. A gravid uterus in pregnancy is supplied by the bilateral uterine arteries which undergo various physiological changes to maintain this high-volume flow.[1] Measuring the blood flow of uterine arteries is therefore of utmost importance to monitor the growth and well-being of the fetus. Hypertension in pregnancy is known since ancient times of Greeks and Hippocrates.[2] Preeclampsia is a significant cause of maternal and fetal morbidity and mortality in a developing country like India where the health-care system is still not up to the mark. Preeclampsia may further precipitate into eclampsia in the mother if not detected early and treated adequately. It may further lead to advanced maternal pathologies associated with liver-Hemolysis, Elevated Liver enzymes, Low Platelets syndrome; kidneys-failure, thorax-congestive cardiac failure, pulmonary edema; central nervous system-hypertension-associated encephalopathy; coagulopathies-disseminated intravascular coagulation and also abruption and accentuated chances of cesarean section. While in the fetus, it may cause intrauterine growth restriction (IUGR), preterm deliveries, birth asphyxia, or even intrauterine fetal death.[3] Assessment of vessels by color Doppler ultrasound is a popular antenatal procedure as it is radiation free and noninvasive; it does not involve any contrast media injections. Doppler assessment is not only a screening tool but its parameters also give a diagnostic value in the prediction of preeclampsia, IUGR, small for gestational age babies, and adverse pregnancy outcomes. Early screening is of value also due to the low sensitivity of the biochemical markers and laboratory investigations for the same. Doppler scans at 22–24 weeks and above in patients with strong suspicion have shown to have significantly raised pulsatility index (PI) in various studies with progression to preeclampsia or pregnancy-induced hypertension and further resulted in adverse pregnancy outcomes. There is evidence of abnormalities associated with waveforms where there is low-resistance flow in the early diastole consistent with a notch. This endothelium disease specific to pregnancy shows an otherwise persistent high-resistance pattern of flow in the uterine arteries which indirectly reflects a placentation abnormality.[4],[5]

Babies born to mothers with preeclampsia are found to be at a high risk of hypertension, diabetes Type II, and cardiovascular abnormality. An abnormal placenta leads to inadequate flow in the uteroplacental circulation A diastolic notch is normally present till 24 weeks of gestation. A persistent notch beyond this age and abnormality in the flow velocity is documented to be a result of trophoblastic invasion inadequacy.[6] Although numerous biochemical tests are used in the screening of preeclampsia, their predictive values and patient compliance are less and are expensive for routine purposes.[7] Ultrasound and Doppler ultrasonography are commonly used in fetal biometry and diagnosis of various congenital anomalies. It is inexpensive, irradiation free, and noninvasive and serves as a great tool for predicting high-risk pregnancy-related conditions such as pregnancy-induced hypertension and IUGR. We undertook this review to investigate the accuracy of uterine artery Doppler indices in predicting preeclampsia.

Inclusion criteria

  1. Studies were done on a high-risk patient with abnormal uterine artery Doppler indices
  2. Studies were done to predict preeclampsia by performing uterine artery Doppler studies
  3. Ultrasound Doppler evaluation of preeclampsia.


Exclusion criteria

  1. Studies not conducting uterine artery Doppler
  2. Studies not associated with preeclampsia
  3. Case reports, commentaries, duplicate data, and review articles were excluded.



  Methodology Top


Our narrative review was performed using the search terms preeclampsia and uterine artery Doppler as the Medical Subject Heading terms. References were managed in Zotero. The search was performed on Google Scholar and PubMed. The search results were limited to papers in English and limited to the years 2016–2020. Articles with the following inclusion criteria were selected for the final analysis: uterine artery Doppler indices usage for predicting preeclampsia throughout the pregnancy irrespective of the gestational age. Those studies which did not fulfill the inclusion criteria were removed. Case reports, documentaries, review articles, and duplicate data were excluded. Nine studies were thus included.


  Results and Observations Top


A total of nine articles were considered for the evaluation of preeclampsia based on uterine artery Doppler ultrasound in patients having a risk to develop hypertension in pregnancy. These studies were done between 2016 and 2020. A total of 1916 cases were studied. Out of these cases, 289 patients were preeclamptic. The study characteristics are listed in [Table 1].
Table 1: All the articles studied in this review

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The primary goal of this review is that uterine artery Doppler indices can reliably predict preeclampsia. In addition, abnormal uterine artery Doppler values are often associated with adverse pregnancy outcomes. It is seen that hypertensive disorders of pregnancy are a result of abnormal placentation and spiral arteries' inability to transform into low-resistance high-volume nonresponsive vessels.[8] The incidence of preeclampsia in the cases studied ranged from a meager 3.5% to a colossal 65% with interobserver reliabilities ranging from moderately accurate to almost flawless. Uterine artery Doppler ultrasound is also considered a good screening tool as most biomarkers which are based on endothelial dysfunction deemed to be inaccurate and undependable.[9]

Thakur and Mehra[10] in 2019 studied 100 patients; 23 developed hypertensive disorder and 19 out of which 23 developed were preeclamptic. Cases with preeclampsia had a mean PI of 1.0 and mean resistive index (RI) of 0.50, although systolic/diastolic (S/D) and notch had no significant association. In their study, there was a significant association between elevated uterine artery RI with a cutoff value of ≥ 0.5 (area under the curve [AUC] 0.759) as a good predictor of preeclampsia. It was followed by uterine artery PI (AUC 0.525).

Jan and Rasool[11] concluded that uterine artery Doppler notch with a high sensitivity of 60% was the best predictor of preeclampsia. Out of 226 women, 22 developed hypertension, 12 (5%) had gestational hypertension, and 8 (3.5%) developed preeclampsia, 2 out of the 8 developed eclampsia. Uterine artery Doppler was found abnormal in 34 (15%) cases.

In a study conducted by Okwudire, et al.[12] on 170 patients, 13 (8%) developed preeclampsia. A significant association was found between the uterine PI, S/D, and combined test with preeclampsia. Combined test had the highest sensitivity (53.8%), whereas PI had the highest specificity of 95.5% closely, followed by the diastolic notch (92.9%). Although the study had high sensitivity with all indices, abnormal PI had a high likelihood to predict preeclampsia.

Thirty-seven patients out of 150 developed preeclampsia in a study conducted by Razavi et al.[13] in 2019 and 30 of those 37 with preeclampsia had abnormal Doppler which was a high number concluding that Doppler studies can reliably predict the condition. They also found that maternal and fetal complications are higher in patients with abnormal Doppler.

In a case‒control study with 40 preeclamptic patients, Sultana et al.[4] found that Doppler values were much higher in the case group. Uterine artery PI and RI of patients with pulmonary embolism (PE) patients were 2.497 ± 0.369 and 1.12 ± 0.0846, respectively. An early uterine artery diastolic notch was found in 90% of preeclamptic patients.

Adekanmi et al.[14] studied 98 high-risk patients, out of which 61 (62.2%) had preeclampsia. Mean RI, PI, and S/D of patients with preeclampsia were 0.59, 1.38, and 2.79, respectively. ROC curve showed that uterine artery PI could predict 86% of cases of PE (AUC = 0.862).

Rashid et al.[15] studied 162 women and evaluated their uterine artery for a diastolic notch. They found that 34% of women had a diastolic notch, of which almost all later developed preeclampsia.

Verma and Gupta.[16] found that 35 out of the 165 patients in their study showed an abnormal second-trimester uterine artery Doppler. Median uterine artery PI was 1.52 in patients with preeclampsia. Abnormal uterine artery Doppler had a high predictive value (36.84%) for preeclampsia.

Li et al.[17] in their study on 760 patients with 100 controls used serum biochemical markers and uterine artery Doppler PI. In 38 preeclamptic, it was found that PI was increased with values of 1.61 ± 0.047. AUC for biomarker and uterine artery PI together was 0.915.


  Discussion Top


Preeclampsia is raised blood pressure in pregnancy following which the spasm of the vascular system causes decreased organ perfusion, further leading to systemic symptoms.[18] There are various complications associated with hypertensive disorder of pregnancy, thus causing the number of death in pregnant women, and thus, a noninvasive technique like Doppler ultrasound is beneficial to evaluate the blood flow along with the uterus and placenta.[19],[20]

While an effective treatment for preeclampsia and IUGR is not found; the National Institute for Health and Care Excellence guidelines suggest that regular antenatal visits and ultrasound examinations for growth evaluation and Doppler studies in high-risk patients are important. As most iatrogenic procedures cannot be performed over pregnant mothers' assessment with the help of Doppler ultrasound is of utmost importance to classify mothers into preeclamptic and fetuses into growth retarded. Thus, most researchers have found that uterine artery Doppler PI is most sensitive benefiting not only high-risk pregnancies but also while assessing the low-risk population groups.[21]

Identification of preeclampsia based on uterine artery Doppler ultrasound is as follows:

Uterine artery Doppler PI is the most used index which when high is considered abnormal and is a good predictor of preeclampsia, however, many researchers also consider uterine artery notch as a valuable index.[20]

In conjunction with preeclampsia, Doppler studies can also predict other associated pregnancy-related conditions namely, IUGR, fetal distress, preterm delivery, placental abruption, and placental insufficiency, thus reducing maternal and fetal mortality significantly.[22]

On the basis of uterine artery RI values (mean RI ≥ 0.5), Thakur and Mehra[10] concluded that uterine artery Doppler could be used as a predictor of preeclampsia. While Jan and Rasool[11] found uterine artery Doppler notch the best predictor in the study; Okwudire et al.[12] and Razavi et al.[13] found uterine artery PI as the most specific followed by all indices combined. Adekanmi et al.[14] and Verma and Gupta[16] found similar results with PI being the best predictor of preeclampsia among all indices. A case‒control study of Sultana et al.[4] showed higher PI and RI values with early diastolic notching in preeclamptic patients, thus concluding that uterine artery Doppler ultrasound can predict preeclampsia at an early stage with high confidence. Rashid et al.[15] concluded that uterine artery Doppler indices can be used to assess prognosis in preeclampsia and IUGR. Finally, Li et al.[17] from their study concluded that even though uterine artery PI is valuable, the highest predictive value is with a combination of three serum markers and uterine artery Doppler PI.


  Conclusion Top


After thorough research, we conclude that preeclampsia has variable incidence depending on the health-care facilities and geographical conditions. From the results, we have seen that majority of the studies have found uterine artery Doppler PI is the best predictor. Even though the results vary depending on different pregnancy characteristics, we can say with high confidence that abnormal ultrasound Doppler of the uterine artery can predict preeclampsia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ratiu D, Hide-Moser K, Morgenstern B, Gottschalk I, Eichler C, Ludwig S, et al. Doppler indices and notching assessment of uterine artery between the 19th and 22nd week of pregnancy in the prediction of pregnancy outcome. In vivo 2019;33:2199-204.  Back to cited text no. 1
    
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Chesley LC. A short history of eclampsia. Obstet Gynecol 1974;43:559-602.  Back to cited text no. 2
    
3.
Osungbade KO, Ige OK. Public health perspectives of preeclampsia in developing countries: Implication for health system strengthening. J Pregnancy 2011;2011:481095.  Back to cited text no. 3
    
4.
Sultana S, Yasmin T, Roy SK, Hossain MS, Amin AA. Prediction of preeclampsia in pregnant population using diastolic notch of uterine artery by duplex color Doppler study. J Enam Med Col 2020;10:33-8.  Back to cited text no. 4
    
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Digiacinto D, Graves M. Uterine artery Doppler and Its value in predicting preeclampsia. J Diagnostic Med Sonography 2009;25:73-7.  Back to cited text no. 5
    
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Cnossen JS, Morris RK, ter Riet G, Mol BW, van der Post JA, Coomarasamy A, et al. Use of uterine artery Doppler ultrasonography to predict pre-eclampsia and intrauterine growth restriction: A systematic review and bivariable meta-analysis. CMAJ 2008;178:701-11.  Back to cited text no. 6
    
7.
Montan S, Sjöberg NO, Svenningsen N. Hypertension in pregnancy-fetal and infant outcome a cohort study. Clin Exp Hypertens. Part B: Hypertens Pregnancy 1987;6:337-48.  Back to cited text no. 7
    
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Young BC, Levine RJ, Karumanchi SA. Pathogenesis of preeclampsia. Annu Rev Pathol 2010;5:173-92.  Back to cited text no. 8
    
9.
Daskalakis G, Antsaklis A. Uterine artery Doppler in the prediction of preeclampsia and adverse pregnancy outcome. Donald school J ultrasound Obstet Gynecol 2010;4:117-22.  Back to cited text no. 9
    
10.
Thakur M, Mehra R. Role of second trimester uterine artery Doppler for the prediction of preeclampsia in high risk pregnancy. Int J Reprod Contracept Obstet Gynecol 2019;8:906.  Back to cited text no. 10
    
11.
Jan S, Rasool T. Prediction of preeclampsia by uterine artery Doppler. Int J Clin Obstet Gynaecol 2020;4:144-7.  Back to cited text no. 11
    
12.
Okwudire EG, Atalabi OM, Ezenwugo UM. The use of uterine artery Doppler indices for prediction of pre-Eclampsia in Port-Harcourt, Nigeria. Niger Postgrad Med J 2019;26:223-9.  Back to cited text no. 12
[PUBMED]  [Full text]  
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Razavi M, Rashidi Fakari F, Jafari FS, Farzaneh F, Sargolzaei N. The role of uterine artery doppler ultrasound in the second trimester in predicting preeclampsia. Int J Pediatrics 2019;7:9405-11.  Back to cited text no. 13
    
14.
Adekanmi AJ, Roberts A, Akinmoladun JA, Adeyinka AO. Uterine and umbilical artery Doppler in women with pre-eclampsia and their pregnancy outcomes. Niger Postgrad Med J 2019;26:106-12.  Back to cited text no. 14
[PUBMED]  [Full text]  
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Rashid MN, Kari M, Rashid R, Rana MA, Amjad A, Hafeez MM. Uterine artery doppler indices as predictive measures for the pre-eclampsia and intrauterine growth restriction. Biological and Clinical Sciences Research Journal. 2020;2020(1).  Back to cited text no. 15
    
16.
Verma D, Gupta S. Prediction of adverse pregnancy outcomes using uterine artery Doppler imaging at 22-24 weeks of pregnancy: A North Indian experience. Turk J Obstet Gynecol 2016;13:80-4.  Back to cited text no. 16
    
17.
Li L, Zheng Y, Zhu Y, Li J. Serum biomarkers combined with uterine artery Doppler in prediction of preeclampsia. Exp Ther Med 2016;12:2515-20.  Back to cited text no. 17
    
18.
Ciobanu A, Rouvali A, Syngelaki A, Akolekar R, Nicolaides KH. Prediction of small for gestational age neonates: Screening by maternal factors, fetal biometry, and biomarkers at 35-37 weeks' gestation. Am J Obstet Gynecol 2019;220:486.e1-11.  Back to cited text no. 18
    
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Damodaram M, Story L, Eixarch E, Patel A, McGuinness A, Allsop J, et al. Placental MRI in intrauterine fetal growth restriction. Placenta 2010;31:491-8.  Back to cited text no. 19
    
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Harman CR, Baschat AA. Comprehensive assessment of fetal wellbeing: which Doppler tests should be performed? Curr Opin Obstet Gynecol 2003;15:147-57.  Back to cited text no. 20
    
21.
Llurba E, Carreras E, Gratacós E, Juan M, Astor J, Vives A, et al. Maternal history and uterine artery Doppler in the assessment of risk for development of early- and late-onset preeclampsia and intrauterine growth restriction. Obstet Gynecol Int 2009;2009:275613.  Back to cited text no. 21
    
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Malik A, Jee B, Gupta SK. Preeclampsia: Disease biology and burden, its management strategies with reference to India. Pregnancy Hypertens 2019;15:23-31.  Back to cited text no. 22
    



 
 
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