Clinical significance of intermittent absent end-diastolic flow of the umbilical artery in fetal growth restriction

Published:November 08, 2022DOI:


      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.


      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.


      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.


      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).


      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.


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      1. Fetal growth restriction: ACOG Practice Bulletin, Number 227. Obstet Gynecol 2021;137:e16–28.

        • Resnik R.
        Intrauterine growth restriction.
        Obstet Gynecol. 2002; 99: 490-496
      2. 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.

        • Blue NR
        • Yordan JMP
        • Holbrook BD
        • Nirgudkar PA
        • Mozurkewich EL.
        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
        • Baschat AA
        • Gembruch U
        • Reiss I
        • Gortner L
        • Weiner CP
        • Harman CR.
        Relationship between arterial and venous Doppler and perinatal outcome in fetal growth restriction.
        Ultrasound Obstet Gynecol. 2000; 16: 407-413
        • Isalm ZS
        • Dileep D
        • Munim SH.
        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
        • Unterscheider J
        • Daly S
        • Geary MP
        • et al.
        Optimizing the definition of intrauterine growth restriction: the multicenter prospective PORTO study.
        Am J Obstet Gynecol. 2013; 208: e1-e6
        • Karsdorp VHM
        • van Vugt JMG
        • van Geijn HP
        • et al.
        Clinical significance of absent or reversed end diastolic velocity waveforms in umbilical artery.
        Lancet. 1994; 344: 1664-1668
        • Rosner J
        • Rochelson B
        • Rosen L
        • Roman A
        • Vohra N
        • Tam Tam H
        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
        • Lewkowitz AK
        • Tuuli MG
        • Cahill AG
        • Macones GA
        • Dicke JM.
        Perinatal outcomes after intrauterine growth restriction and intermittently elevated umbilical artery Doppler.
        Am J Obstet Gynecol MFM. 2019; 1: 64-73
        • Madden JV
        • Flatley CJ
        • Kumar S.
        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
        • Caradeux J
        • Martinez-Portilla RJ
        • Basuki TR
        • Kiserud T
        • Figueras F.
        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
        • Boers KE
        • Vijgen SM
        • Bijlenga D
        • et al.
        Induction versus expectant monitoring for intrauterine growth restriction at term: randomised equivalence trial (DIGITAT).
        BMJ. 2010; 341: c7087
        • Lees C
        • Marlow N
        • Arabin B
        • et al.
        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
        • Lees CC
        • Marlow N
        • van Wassenaer-Leemhuis A
        • et al.
        2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial.
        Lancet. 2015; 385: 2162-2172
        • Berkley E
        • Chauhan SP
        • Abuhamad A.
        • Society for Maternal-Fetal Medicine Publications Committee
        Doppler assessment of the fetus with intrauterine growth restriction.
        Am J Obstet Gynecol. 2012; 206: 300-308