BACKGROUND
Fetal growth restriction can result from a variety of maternal, fetal, and placental
conditions. Umbilical artery Doppler assesses the impedance to blood flow along the
fetal component of the placental unit. An abnormal umbilical artery waveform reflects
the presence of placental insufficiency and can help differentiate a growth-restricted
fetus from the constitutionally small, thus guiding further management. The presence
of persistently absent end-diastolic flow and reversed end-diastolic flow is an indication
for inpatient antenatal surveillance and preterm delivery. There is no consensus on
the optimal management of intermittent absent end-diastolic flow owing to a lack of
data to support the ideal delivery timing for growth-restricted fetuses with this
finding.
OBJECTIVE
This study aimed to estimate the risks of adverse perinatal outcomes among growth-restricted
pregnancies with persistently elevated, intermittently absent, and persistently absent
end-diastolic flow. Fetal growth restriction is a common condition that is associated
with an increased risk of fetal morbidity and mortality. Intermittently absent umbilical
artery end-diastolic flow may be identified among pregnancies with fetal growth restriction.
The fetal risks associated with persistently absent end-diastolic flow have been described.
However, the risks associated with intermittent absent end-diastolic flow are not
as well-known.
STUDY DESIGN
We performed a retrospective cohort study including nonanomalous, singleton, growth-restricted
pregnancies that received umbilical artery Doppler assessment at our institution from
2009 to 2020. Fetuses were classified into the following 3 categories: elevated umbilical
artery Doppler, intermittent absent end-diastolic flow, and persistently absent end-diastolic
flow. The Doppler categories were classified by the most severe in the pregnancy.
The primary outcome was a composite of neonatal morbidity.
RESULTS
Total 233 fetuses met the criteria. Of which 78 (33.0%) had elevated umbilical artery
Doppler waveforms, 37 (16.0%) had intermittent absent end-diastolic flow, and 119
(51.0%) had absent end-diastolic flow. The composite outcome was statistically different
between the groups, occurring in 16.9% with elevated umbilical artery Doppler waveforms
(13/77), 35.1% (12/39) with intermittent absent end-diastolic flow, and 56.3% (65/127)
with absent end-diastolic flow (P<.001). The odds ratio for the composite outcome was significantly increased in absent
end-diastolic flow (odds ratio, 6.15; 95% confidence interval, 3.14–12.80) and was
not significantly increased for intermittently absent end-diastolic flow (odds ratio,
2.46; 95% confidence interval, 0.98–6.19) when compared with elevated umbilical artery
Doppler waveforms. When adjusted for gestational age at delivery and antenatal steroids,
no difference was seen in the primary outcome for intermittent absent end-diastolic
flow (adjusted odds ratio, 0.73; 95% confidence interval, 0.20–2.68) and absent end-diastolic
flow (adjusted odds ratio, 1.44; 95% confidence interval, 0.51–4.07).
CONCLUSION
Among growth-restricted pregnancies, intermittent absent end-diastolic flow is associated
with a similar rate of composite neonatal morbidity as persistently elevated Doppler
waveforms. In addition, there is no difference in composite neonatal morbidity between
the 3 groups when corrected for gestational age at delivery and antenatal steroid
administration. These similar outcomes should be considered when creating an antenatal
surveillance plan and discussing the potential for outpatient management.
Keyword
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of Obstetrics & Gynecology MFMAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
Fetal growth restriction: ACOG Practice Bulletin, Number 227. Obstet Gynecol 2021;137:e16–28.
- Intrauterine growth restriction.Obstet Gynecol. 2002; 99: 490-496
Society for Maternal-Fetal Medicine (SMFM). Electronic address: [email protected], MartinsJG, BiggioJR, AbuhamadA. Society for Maternal-Fetal Medicine Consult Series #52: diagnosis and management of fetal growth restriction: (replaces Clinical Guideline Number 3, April 2012). Am J Obstet Gynecol 2020;223:B2–17.
- Abdominal circumference alone versus estimated fetal weight after 24 weeks to predict small or large for gestational age at birth: a meta-analysis.Am J Perinatol. 2017; 34: 1115-1124
- Relationship between arterial and venous Doppler and perinatal outcome in fetal growth restriction.Ultrasound Obstet Gynecol. 2000; 16: 407-413
- Prognostic value of obstetric Doppler ultrasound in fetuses with fetal growth restriction: an observational study in a tertiary care hospital.J Matern Fetal Neonatal Med. 2015; 28: 12-15
- Optimizing the definition of intrauterine growth restriction: the multicenter prospective PORTO study.Am J Obstet Gynecol. 2013; 208: e1-e6
- Clinical significance of absent or reversed end diastolic velocity waveforms in umbilical artery.Lancet. 1994; 344: 1664-1668
- Intermittent absent end diastolic velocity of the umbilical artery: antenatal and neonatal characteristics and indications for delivery.J Matern Fetal Neonatal Med. 2014; 27: 94-97
- Perinatal outcomes after intrauterine growth restriction and intermittently elevated umbilical artery Doppler.Am J Obstet Gynecol MFM. 2019; 1: 64-73
- Term small-for-gestational-age infants from low-risk women are at significantly greater risk of adverse neonatal outcomes.Am J Obstet Gynecol. 2018; 218: e1-e9
- Risk of fetal death in growth-restricted fetuses with umbilical and/or ductus venosus absent or reversed end-diastolic velocities before 34 weeks gestation: a systematic review and meta-analysis.Am J Obstet Gynecol. 2018; 218 (e21): S774-S782
- Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT).BMJ. 2010; 341: c7087
- Perinatal morbidity and mortality in early-onset fetal growth restriction: cohort outcomes of the trial of randomized umbilical and fetal flow in Europe (TRUFFLE).Ultrasound Obstet Gynecol. 2013; 42: 400-408
- 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial.Lancet. 2015; 385: 2162-2172
- Doppler assessment of the fetus with intrauterine growth restriction.Am J Obstet Gynecol. 2012; 206: 300-308
Article info
Publication history
Published online: November 08, 2022
Accepted:
November 3,
2022
Received in revised form:
November 1,
2022
Received:
August 10,
2022
Footnotes
The authors report no conflict of interest.
No funding was provided in the conduction of this research or preparation of the article.
This study was presented at the annual meeting of the American Institute of Ultrasound in Medicine, San Diego, CA, March 12–16, 2022.
Identification
Copyright
© 2022 Elsevier Inc. All rights reserved.
