“ROLE OF UTERINE ARTERY DOPPLER AT 12 TO 16 WEEKS

OF GESTATION IN PREDICTION OF PRE-ECLAMPSIA AN

OBSERVATIONAL STUDY’’

By

DR. AMBIKA PATIL

Dissertation submitted to the

Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka
In partial fulfillment of the requirements for the degree of
MASTER OF SURGERY

IN

OBSTETRICS AND GYNAECOLOGY

Under the guidance of

DR. ASHA NERAVI M.D

PROFESSOR

DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

Sri Dharmasthala Manjunatheshwara College of Medical Sciences
& Hospital
Dharwad - 580009, Karnataka
2014

i
 ACKNOWLEDGEMENT

I am indebted to Prof Dr. Asha Neravi M.D Professor , Obstetrics and

Gynaecology who is my guide in this work and also my revered teacher in

Obstetrics and Gynaecology. I remain ever grateful for her encouragement, guidance

and patience throughout my postgraduate career.

I am indebted to thank my Co-Guide Dr. Shyamsundar K Joshi M.D,

Professor and HOD Department of Radio Diagnosis who not only encouraged me to

take up the study but also guided me in doing the study and helped me throughout in

bringing out the study.

It gives me immense pleasure to express my heart filled thanks to

Dr. Rathnamala M Desai M.D Professor and Head of the Department of Obstetrics

and Gynaecology, SDM College of Medical Sciences and Hospital, for her valuable

guidance, advice and her constant support and encouragement during course of my

study.

Words fail to express my indebtedness to Professor Dr. Hemalata S.

Mahantshetti for her support understanding and concern throughout the years of my

study.

I thank Professor Dr. Sunil Kumar of the Department of Obstetrics and

Gynaecology for his availability and willingness to teach at any time. I remain

grateful for his encouragement in my career.

I express my heartfelt gratitude to Associate Professor Dr. Rameshkumar,

Department of Obstetrics and Gynaecology, who encouraged me and was constant

support

vii
 LIST OF ABBREVATIONS

A Cross sectional area

At The vascular cross sectional area at the instant of the velocity

measurement
C Propagation speed of sound in the medium

CDI Doppler shift frequency

FDA Food and Drug Administration

FGR Fetal Growth Restriction

Fr Received frequency

Ft Transmitted frequency

FTND Full Term Normal Delivery

GA1 Gestation Age at transvaginal scan

GA2 Gestation Age at transabdominal scan

ISATA Spatial Average, Temporal Average Intensity

IUGR Intra Uterine Growth Restriction

SDMCMSH Sri Dharmasthala Manjunatheshwara College of Medical

Sciences & Hospital
LMP Last Menstrual Period

LSCS Lower Segment Caesarean Section

NPV Negative Predictive Value

NICU Neonatal Intensive Care Unit

N1 Uterine artery Doppler notching at 12-16 weeks gestation

N2 Uterine artery Doppler notching at 24-26 weeks gestation

OPD Outpatient Department

PI Pulsatality Index PI1: Pulsatality Index at 12-16 week

PI2: Pulsatality Index at 24-26 week

ix
PTVD Preterm Vaginal Delivery

Qt Instantaneous flow

R Radius

RBC Red Blood Cells

RI Resistance RI1: Resistance Index at 12-16 week

Index RI2: Resistance Index at 24-26 week
S/D Systolic/Diastolic

US United States

V The velocity of the scatter in a given direction

Vt The spatial mean velocity measurement

x
 ABSTRACT

BACKGROUND:

Pre-eclampsia affects 2% - 5% of pregnancies is the major cause of perinatal

and maternal morbidity and mortality.

Doppler is a non-invasive method for evaluation of feto-placental circulation

without any disturbance to human pregnancy.

A high resistance index and persistent uterine artery notching, pulsatility index

in uterine artery Doppler waveform has shown as the best screening test.

Thus, we have conducted this study to find out the predictive value of

transvaginal Doppler in early pregnancy for the prediction and sub-sequent perinatal

outcome.

AIM OF STUDY:

The aim of the study was early prediction of pre-eclampsia and its

obstetrical outcome by trans-vaginal uterine artery Doppler study at 12-16

weeks.

METHODOLOGY:

After assessment of inclusion and exclusion criteria 100 antenatal women of 12

to 16 weeks of singleton pregnancy were selected for the study in the department of

Obstetrics and Gynaecology of S.D.M. Medical College Dharwad. Women booking

for antenatal care were examined and investigated. After an informed consent, the

women were subjected to transvaginal ultrasound for dating and screening scan.

Women were placed in the dorsal position with knee flexed, a trans-vaginal

xi
ultrasound dating scan was done and Doppler assessment of uterine circulation for

uterine artery indices. These women were again rescanned at 24-26 weeks of

gestation by transabdominal USG and further followed up clinically for development

of preeclampsia.

RESULTS

Out of 100 women, 22 patients developed preeclampsia. In our study 35% of

women had B/L uterine artery notching, mean RI is 0.57, PI is 0.89 at 12-16 weeks.

When uterine artery notch at 12-16 weeks alone is considered, 34.28% of women

developed preeclampsia. Detection rate increased upto 85.71% when RI>0.65 is also

included along with uterine artery Doppler diastolic notching. Uterine artery notching

at 12-16 weeks gestation has 84.62% specificity, 70.51% NPV. When notch and RI

>0.65 considered together sensitivity increases by 85.71% and NPV by 98.25%.

CONCLUSION

The uterine artery notching, high Resistance Index and Pulsatility Index in

uterine artery Doppler waveform at 12-16 weeks has shown as best screening test for

early prediction of preeclampsia

KEY WORDS

Preeclampsia; Uterine artery Doppler; Uterine artery notch

xii
 TABLE OF CONTENTS

SL NO CONTENTS PAGE NO

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 3

3 REVIEW OF LITERATURE 4

Brief history 4

Physical Principles of Doppler Ultrasonography 6

Pathophysiology of Preeclampsia 19

4 METHODOLOGY 31

5 RESULTS AND OBSERVATIONS 34

6 DISCUSSION 58

7 CONCLUSION 62

8 SUMMARY 63

9 BIBLIOGRAPHY 65

10 ANNEXURE 74

xiii
 LIST OF TABLES

SL CONTENT Page No
NO
1 Age distribution in years 35

2 Educational status 36

3 Socioeconomic status 37

4 Parity distribution 38

5 Statistical analysis of gestation age at scan 39

6 Systolic blood pressure in study group in third trimester 40

7 Diastolic blood pressure in study group third trimester 41

8 Uterine artery Doppler diastolic notching at 12-16 weeks 42

9 Uterine artery Doppler diastolic notching at 24-26 weeks 43

10 Association of uterine artery diastolic notch with 44

development of preeclampsia
11 Resistance Index and Pulsatility Index in study group 45

12 Association of at 12-16 week and 24-26 week of gestation 46

Uterine artery Doppler indices in preeclamptic and in
normal pregnant women
13 Association of uterine artery notch and RI at 12-16 week of 48
gestation in preeclamptic and in non preeclamptic women.
14 Comparison of uterine artery notch alone and uterine 49
artery notch with RI>0.65 with development of
preeclampsia
15 Association of at 12-16 week and 24-26 week of gestation 50
Uterine artery Doppler pulsatility index in preeclamptic
and in normal pregnant women
16 Role uterine artery Doppler in predicting preeclampsia at 52
12-16 weeks

xiv
17 Gestation age at delivery in weeks 53

18 Gestation age at delivery in preeclamptic women 54

19 Mode of delivery 55

20 Descriptive statistics for birth weight, APGAR score, NICU 56

stay
21 Neonatal outcome in preeclampsia 57

xv
 LIST OF FIGURES

SL NO CONTENTS Page No
1 Doppler effect when an ultrasound beam interrogates 7
circulating blood
2 The typical waveform of blood flow 14
3 The waveform with a notch (D) 15
4 Anatomy arcuate, radial, and spiral arteries during 18
pregnancy
5 Difference between normal and preeclamptic pregnancies 21
regarding the extent of physiological changes in the
uteroplacental arteries
6 Uterine artery waveform with early diastolic notch 30

xvi
 LIST OF GRAPHS

SL NO CONTENT PAGE NO

1 Age distribution in years 35

2 Educational status 36

3 Socioeconomic status 37

4 Parity distribution 38

5 Statistical analysis of gestation age at scan 39

6 Systolic blood pressure in study group in third trimester 40

7 Diastolic blood pressure in study group in third 41

trimester
8 Uterine artery Doppler diastolic notching at 12-16 42
weeks
9 Uterine artery Doppler diastolic notching at 24-26 43
weeks
10 Association of uterine artery diastolic notch with 44
development of preeclampsia
11 Resistance Index and Pulsatility Index in study group 45

12 Association of resistance index at 12-16 week and 24-26 47

week of gestation Uterine artery Doppler indices in
preeclamptic and in normal pregnant women
13 Association of uterine artery notch and RI at 12-16 48
week of gestation in preeclamptic and in non
preeclamptic women.
14 Comparison of uterine artery notch alone and uterine 49
artery notch with RI>0.65 with development of
preeclampsia
15 Association of at 12-16 week and 24-26 week of 51
gestation Uterine artery Doppler pulsatility index in
preeclamptic and in normal pregnant women
16 Role uterine artery Doppler in predicting preeclampsia 52
at 12-16 weeks

xvii
17 Gestation age at delivery in weeks in preeclamptic 54
women
18 Mode of delivery 55

19 Descriptive statistics for birth weight, APGAR score, 56

NICU stay
20 Neonatal outcome in preeclampsia 57

xviii
 INTRODUCTION

Preeclampsia and intrauterine growth restriction are important causes of

maternal morbidity and mortality1,2.

According to National centre for health statistics in 1998, hypertension

associated with pregnancy was common medical risk factor. Preeclampsia was

identified in 1, 46,320 women or 3.7% of all pregnancies that ended in live births3.

Berg and colleagues (1996) reported almost 18% of 1450 maternal deaths in United

States 1987 to 1990 were complications of pregnancy related hypertension4.

Hypertension in pregnancy is also responsible for fetal (more than 19 weeks of

gestation) and infant mortality as well as 46% of infants born small for gestation2.

Similarly it was estimated that 3-10% of infants are growth restricted. Fetal

growth restriction is associated with substantiative perinatal morbidity and

mortality6,7. This is true for both preterm and term infants8.

Early screening for preeclampsia may allow vigilant antenatal surveillance and

appropriate timing of fetal delivery in order to avoid serious sequelae. Various

haemodynamic and biochemical measures have been found to have limited accuracy

as a screening measures for this condition9,10.

Preeclampsia is characterised by an imbalance between prostacycline and

thrombaxane A2 production11 as well as failure of the second wave trophoblastic

invasion of the endometrio -myometrial vasculature. The result is abnormal

uteroplacental blood flow and this lead an idea of using Doppler assessment of uterine

artery velocimetry waveforms as the method of screening for this antenatal

complication12.

1
 In recent years, ultrasonography is commonly used in measurement of fetal

biometry and diagnosis of congenital anomalies and IUGR. Problem which still exists

is identification of those pregnancies which are at risk of increased maternal and fetal

morbidity as in pregnancy induced hypertension2.

Various biochemical tests used in screening of high risk population for pre-

eclampsia have lower positive predictive values, high cost and less patient

compliance.2

Doppler is a non-invasive method for evaluation of feto-placental circulation

without any disturbance to human pregnancy.3

A high Resistance Index, Pulsatility Index and persistent uterine artery

notching in uterine artery Doppler wave form has shown as the best screening test.2

Thus, we have conducted this study to find out the predictive value of

transvaginal Doppler in early pregnancy at 12-16 week of gestation for the prediction

of preeclampsia and sub-sequent perinatal out come.

2
 AIMS AND OBJECTVES

OBJECTIVE OF THE STUDY:

Early prediction of pre-eclampsia and its obstetrical outcome by transvaginal uterine

artery Doppler study.

3
 REVIEW OF LITERATURE

BRIEF HISTORY

Christian Andreas Doppler and the Doppler Theory:

The Doppler effect is defined as the observed changes in frequency of

transmitted waves when relative motion exists between the source of the wave and

observer. The frequency increases when source and the Observer move closer and

decreases when they move apart. This phenomenon bears the name of its discoverer

Christian Andreas Doppler an Austrian mathematician and physicist.

The first pulsed wave Doppler equipment was developed by the Seattle

Research team. Donald Baker, Dennis Watkins and John Reid began working on this

project in 1966 and produced one of the first pulsed Doppler devices14. The Seattle

team also pioneered the construction of Duplex Doppler instrumentation. Based on

mechanical sector scanning head in which a single transducer crystal performs both

imaging and Doppler functions on a time-sharing basis. The Duplex Doppler

technique allowed the ultrasound operator to determine for the first time the target of

Doppler insonation. This development is of critical importance in Obstetrics and

Gynecological applications, as such range discrimination allows reliable Doppler

interrogation of a deep lying circulation, such as that of the fetus and of the maternal

pelvic organs.

Development of Color Doppler Ultrasonography:

Spectral Doppler Ultrasound interrogates along the single line of Ultrasound

beam transmission. The haemodynamic information thus generated is limited to

unidimentional flow velocity characterization from the target area. This limitation

4
provided the impetus to develop a method for depiction of flow in a two dimensional

planes in a real time.

The development of real time two-dimensional color Doppler

ultrasonography therefore represents a major technologic breakthrough, which

becomes possible because of introduction of two critical pieces of technology for

processing the Doppler ultra sound signal. First were the Doppler sonographic

applications by Angelsen and Kristofferson15 of the sophisticated filtering technique

of the ―moving target indicator‖ used in radar system. This filter allows removal of

high amplitude low velocity clutter signals generated by movement of tissues

structure and vessel walls. The second was development of auto correlation

techniques by Namekawa et al16. The autocorrelater is capable of processing mean

Doppler phase shift data from two dimensional scan areas in real time.

Introduction of Doppler Ultrasonography to Obstetrics and Gynaecology:

The first obstetrics application of Doppler ultrasonography consisted of

detection of fetal heart movements17originally developed for fetal heart rate detection.

The technique was further developed for non-invasive continuous electronic

monitoring of the fetal heart rate.

Currently they constitute the most common uses of Doppler sonography in Obstetrics.

The system is based on utilizing relatively simple continuous wave Doppler

ultrasound to determine the fetal heart rate from the fetal Cardiac wall or Valvular

motion.

The first application of Doppler velocimetry in Obstetrics was reported by

Fitzgerald and Drumm18 and McCallum et al19 .The former are recognized as the first

5
group to publish a peer-reviewed article in this field. These publications were

followed by an era of impressive research productivity during which investigators

extended the use of Doppler velocimetry for assessing various component of fetal and

maternal circulations20-28. These studies utilized continuous wave and duplex-pulsed

wave Doppler technology.

Use of two-dimensional color Doppler flow mapping techniques in

Obstetrics was reported by Devore and associates29 and Maulik and associates30. In

both studies Doppler flow mapping was used to characterize fetal cardiac flow

dynamics. Taylor and colleagues were the first to characterize the Doppler waves

from the ovarian and uterine arterial circulations utilizing pulse duplex Doppler

instrumentation31.

PHYSICAL PRINCIPLES OF DOPPLER ULTRASONOGRAPHY:

DOPPLER EFFECT

The Doppler Effect is the phenomenon of observed changes in the frequency

of energy wave transmission when relative motion occurs between source of wave

transmission and the observer. The change in the frequency is known as Doppler

frequency shift or simply the Doppler shift.

fd = ft - fr

Where fd is the Doppler shift frequency

ft is the transmitted frequency and

fr is the received frequency.

When the source and the observer move closer, the wavelength decreases and

the frequency increases. Conversely, when the source and the observer move apart,

the wavelength increases and the frequency decreases. This principle applies to all
6
forms of wave propagation. The utility of the Doppler effect originates from the fact

that the shift in frequency is proportional to the speed of movement between the

source and the receiver and therefore can be used to assess this speed.

Doppler Ultrasound: The phenomenon of the Doppler Effect is also observed when

an ultrasound beam encounters blood flow. With blood circulation millions of red

blood cells (RBC‘s) act as moving scatters of the incident ultrasound. In this

circumstance the erythrocytes act first as moving receiver and then as moving sources

forming the basis for the Doppler equation32.

fd= 2ft v/c

Where fd represent the Doppler frequency shift,

ft is the frequency of incident beam (transducers frequency)

V the velocity of the scatterer in a given direction and

C is the propagation speed of sound in the medium.

Fig 1: Doppler effect when an ultrasound beam interrogates circulating blood

7
If the direction of the incident beam is at an angle to the direction of blood flow, the

‘V’ in the Doppler equation is replaced by the component of the velocity in the

direction of the flow (Obtained by the cosine of angle cosθ).

fd=2ftcos v/cosθ

To determine velocity of scatterer the equation can be rewritten as follows.

v=fd c/2ft Cosθ

Thus, if the angle of beam incidence and the Doppler shift are known, the

velocity of blood flow is also known, assuming that the transducer frequency and the

velocity of sound in tissue remain relatively constant. The above equation forms the

basis for clinical application of the Doppler principle.

High pass and Low pass filtering: The total signal input of Doppler system is

comprised of not only Doppler frequency shifts signals from the target vessel but also

low frequency high amplitude signals originating from moving adjacent structures

such as vessel wall and cardiac valves. It also contains high frequency noise

contribution within the instrumentation. Obviously the frequency from the extraneous

sources represents error components of total signals and their reduction or elimination

improves the signal quality. Electronic digital filters are used to accomplish this

objective.

Two types of filters are used:

1. High Pass Filter

2. Low Pass Filter

8
 The purpose of high pass filter system is to eliminate the extrinsic low

frequency components of Doppler signals, which arise predominantly from the vessel

wall or other adjacent slow moving structures. This should be used with caution as a

high setting

Eliminates end diastolic frequency shifts from umbilical or uteroplacental circulation.

Low pass filter used for high frequency noise.

Doppler ultrasound equipment are based on detecting changes in frequency that

occur when an ultrasound beam strikes a moving target. Three types of devices can

obtain Doppler signals.

1. Continuous wave Doppler

2. Pulsed wave Doppler

3. Doppler color flow mapping

1. Continuous wave Doppler:

Machine has two crystals one that transmits high frequency sound wave and

another that continuously receives signals. It can record high frequencies using

low power output and is easy to use. Unfortunately it is nonselective and

recognizes all signals along its path and does not allow visualization of blood

vessels of interest. It is useful to detect fetal heart movements or even umbilical

artery pulsation.

2. Pulsed wave equipment:

In late 1970s, Gill described the pulse Doppler technique for measuring blood

flow in umbilical vein33. In pulse Doppler ultrasonic wave is emitted in pulsatile

9
 fashion. Between the pulses of emission, the same transducer operates as a

receiver for the back scattered echoes. Because velocity of sound is known and

presumed to be constant, it is possible to analyze the back scattered echoes alone

from a particular range. The circuit selectively permits only those signals that

arrive to the receiver at a given time after the transmission.

This allows a precise determination of the size of the sample volume that can be

located in particular area33. This transmit and receive sequence is repeated

periodically. The rate at which this is accomplished determines the performance of the

pulse Doppler system. One shortcoming of pulse Doppler arises from the fact that a

new pulse cannot be emitted before the last echo of the preceding pulse has arrived at

the transducer. The integration of real time ultrasonography and pulse Doppler

technique is referred to as duplex Doppler scanning. In duplex scanning it is

customary to locate the target with real time imaging and then to switch on to the

Doppler mode.

3. Color flow Imaging:

The earlier two dimensional flow imaging were based on continuous wave

Doppler and non real time scanning34. In early 1980, a real time two-dimensional

flow imaging technique that utilized an auto correlation processor for the detection of

a moving target was introduced16.

In the current and more sophisticated color Doppler imaging (CDI) color-coded

pulse Doppler information is superimposed on B mode ultrasonic image. In this

method, color is assigned to flow direction. Customarily, flow towards the Doppler

transducers is displayed in red, and flow away from it is shown in blue. The structures

that do not move are presented in basic gray scale image. The color saturation is

10
related to the magnitude of the frequency shift35. Color flow imaging facilitates the

detection of small vessels and the blood flow velocity. Color flow imaging is

subjected to the same limitation as pulse Doppler.

Doppler waveforms: Doppler power spectrum contains an immense amount

of haemodynamic information from the target circulation and is usually displayed as

sonogram. In this sonographic display, the vertical axis shows the magnitude of

frequency shift, the horizontal axis represents the temporal change, and the brightness

of the spectrum is indicative of the amplitude or the power of the spectrum. During

real-time Doppler interrogation, the spectral display scrolls from the left of the screen

to the right with time as progressively newer spectral information is added to the

display.

The maximum and mean frequency shift waveforms are most commonly used

in clinical applications. It should be noted that most Doppler descriptor indices are

based on the maximum frequency value.

Haemodynamic information from Doppler: The Doppler frequency shift

reflects but does not directly measure blood velocity. Doppler ultrasound can generate

wide range of haemodynamic information from simple recognition of the presence of

flow to the velocity profile of flow, quantification of flow, and assessment of

downstream vascular impedance.

Flow Quantification: Doppler ultrasound velocimetry is one of the non-

invasive techniques for flow quantification in humans. (The other being recently

introduced time domain processing approach).

11
 Instantaneous flow can be measured by integrating the mean velocity across

the vascular lumen with the vascular cross sectional area according to the following

equation:

Qt=At .Vt

Where Qt is the instantaneous flow,

At the vascular cross sectional area at the instant of the velocity

measurement,

Vt the spatial mean velocity measurement.

The spatial mean velocity can be determined from the Doppler mean

frequency shift if the angle between the sonic beam and the flow axis is known.

The clinical usefulness of Doppler velocimetry for quantifying flow is limited

as it suffers from several sources of error.

One of the critical concerns is the accuracy of measuring the vascular cross

sectional area, especially of smaller fetal vessels. As the estimation of the area

involves the squaring the radius A=∏ r2 (where A is the cross sectional area R is the

radius) any error in measuring the vessel diameter is significantly amplified in the

calculation of volume flow. Another important source of inaccuracy is the error in

determining the angle of insonation. These limitations has restricted the usefulness of

Doppler based flow estimation in clinical practice.

Doppler waveform analysis and Doppler indices:

The maximum Doppler frequency shift waveform represents the temporal

changes in the peak velocity of the red cell movement during the cardiac cycle. It is

12
therefore under the influence of both upstream and downstream circulatory factors36.

The objective has been to obtain information specifically related to distal circulatory

homodynamic. Techniques have been developed for analyzing this waveform in an

angle independent manner. Most of these analytic techniques involve deriving

Doppler indices or ratios from the various combination of the peak systolic, end

diastolic, and temporal mean values of the maximum frequency shift envelope.

Because these parameters are taken from the same cardiac cycle, these ratios are

virtually independent of the angle of insonation. A unique characteristic of

uteroplacental, fetoplacental and cerebral circulation in the fetus is the continuing

forward flow during diastole. This feature develops progressively in fetoplacental

circulation so that the perfusion of vital organs is uninterrupted throughout the cardiac

cycle. The essential effect of this phenomenon includes not only the progressive

increase in the end diastolic component of the flow velocity but also a concomitant

decrease in the pulsatality, which is the difference between the maximum systole and

the end diastolic components. The pulsatility of the flow velocity was originally

investigated using Doppler ultra sound in the peripheral vascular system.

The blood flow characteristic can be quantified by various Doppler indices

like the systolic/diastolic ratio (S/D), resistance index (RI) and the pulsatility index

(PI) which can be taken on any vessel37,38.

13
 Fig 2: The typical waveform of blood flow

A. Peak systolic velocity

B. End diastolic velocity

C. Early diastolic velocity

M. Mean velocity

The indices are 37,38:

1. S/D ratio : Peak Systolic Velocity A

------------------------------------- = -------
End diastolic Velocity B

2. Resistance Index (RI) i.e. Peak Systolic-End Diastolic A-B

------------------------------------- = ------
Peak Systolic Velocity A

14
 3. Pulsatility Index (PI) : Peak Systolic-End Diastolic Velocity A-B
---------------------------------------------- = ------
Mean Velocity M

Fig 3: The waveform with a notch (D)

S/D ratio gives a simple evaluation of blood flow during diastole and provides

estimation of downstream resistance39. The resistance index or RI is useful when the

diastolic flow is absent or reversed and S/D cannot be calculated40. Hence, it helps in

comparing any waveform irrespective of its diastolic flow.

15
 The pulsatality index considers the mean velocity as diameter i.e. the

whole of the flow is given consideration not just the diastolic flow and hence can be

used to analyze data from various vessels without encountering the excessive

variation that can be caused by division by small numbers as with the other two

indices39.

Sources of variance of Doppler indices

The configuration of an arterial Doppler waveform is modulated by

haemodynamic and non-hemodynamic factors41. The haemodynamic factors may be

short term or long term. Short term includes any change in the impedance or in the

heart rate.

Long-term changes in the impedance include those encountered in the

umbilical circulation with the progression of pregnancy. The most remarkable

influence on the umbilical arterial Doppler indices is that the duration of pregnancy.

As gestation advances the fetoplacental circulation undergoes a consistent increase in

the end diastolic velocity and concomitant decrease in the pulsatality. This is reflected

in Doppler indices.

The S/D ratio, PI and RI decrease throughout pregnancy. The most likely

explanation is the circulation experiences a progressive fall in the impedance with

advancing gestation especially after 20th week. The indices are also affected by

following things:

1. Fetal breathing movements

2. Fetal heart rate

3. Location of measurement
16
Non-Haemodynamic Modalities:

Are those related to the examiner and to the devices and constitute the error

component of the variance in the Doppler indices. Inter observer and intra observer

variations are the main illustrators of such errors.

Safety of Doppler:

Any pelvic application of Doppler ultrasound in the potentially pregnant

patient requires careful consideration of any possible bio effects on developing fetus.

There are two potential mechanisms through which ultrasonography can produce

biologic effects: thermal and mechanical42. Tissue heating i, e the thermal effect, is a

consequence of the tissue absorption of ultrasound wave. Mechanical effects consist

of cavitation and radiation forces.

The degree of tissue heating is determined by ultrasound frequency, intensity,

the area of ultrasound being exposed and exposure time. The type of tissue

intersecting the path of ultrasound beam is crucial as absorption of ultrasound at the

soft tissue/bone interface increases which leads to considerable increase in heat. In

normal diagnostic ultrasonography the estimated rise in temperature does not exceed

10C when ISATA (spatial average, temporal average intensity) remains below

300mw/cms. According to US food and drug administration the highest known

intensity emitted from pre 1976 ultrasonography devices was 94mw/cm. It has been

suggested that temperature rise up to 20 C will not have any harmful effect in an

apyretic patient, but when this limit is exceeded the duration of exposure becomes an

important factor affecting safety43.

17
 Each of the three types of Doppler ultrasound currently in use can be operated

at an intensity level within the FDA guidelines. Continuous wave Doppler devices,

which have long been used by obstetricians employ low intensity output in the range

of 90-80mw/cm. Color flow imaging devices operate at essentially the same output

intensity as conservative gray scale imaging, and thus fall well within the FDA

guidelines. Unfortunately pulse Doppler ultrasound the technique that yields valuable

quantitative information may produce unacceptably high fetal doses if improperly

used.

Fig 4: Anatomy arcuate, radial, and spiral arteries during pregnancy

Anatomy of uterine circulation:

Uterine artery originates from internal iliac artery and meets the uterus just

above the cervix. The main uterine artery branches into arcuate arteries, which arch

anteriorly and posteriorly and extend inward for about 1/3rd thickness of the
18
myometrium. They are tortuous and vary in thickness and in the area they supply. The

arcuate artery network anastomoses near the mid line44. Radial arteries arise from this

network are directed toward the uterine cavity and become spiral artery when they

enter the endometrium.

PATHOPHYSIOLOGY OF PRE-ECLAMPSIA AND FETAL GROWTH

RESTRICTION50

DEFINITION

Pre-eclampsia is a pregnancy specific syndrome of reduced organ perfusion

secondary to vasospasm and endothelial activation. Minimum criteria for pre-

eclampsia are39:

1. BP 140/90mm Hg after 20 weeks gestation

2. Proteinuria 300mg/24 hours or 1 + dipstick

Fetal growth restriction can be broadly defined as an intrauterine fetal growth,

which results in the birth of an infant weighing less than its genetic potential39,45. To

recognize this, various definitions of low birth weight based on percentiles of

weight have been proposed for e.g.

1. < 10th percentile by Battaglia and Lubchenco 199146.

2. < 5th percentile by Seeds, 198447.

The syndrome complex of pre-eclampsia and fetal growth restriction have similar

pathology of placental insufficiency. Here the blood supply to the fetus is inadequate

because of defective placentation which can be part of syndrome of pre-eclampsia or

19
can individually lead to defective growth of the baby i.e. small for gestational age

baby.

Normal growth and development of uteroplacental circulation during

pregnancy During the first 12 weeks of pregnancy cytotrophoblast invade the spiral

arterial walls in the decidua and replace the endothelium and muscular media with a

matrix of cytotrophoblasts and fibrinoid and fibrous tissue48,49. The fibrinoid material

is a complex of maternal fibrin and other plasma constituents plus proteinaceous

material derived from the trophoblastic cells. Beginning at about 12 weeks of

gestation and continuing throughout the remainder of the second trimester, the

endovascular trophoblast move in to the myometrial segments of spiral arteries. Once

again the trophoblast replaces the endothelium and establishes themselves in the

muscular media. The elastic and muscular tissue of the myometrial segments of the

spiral arteries is gradually lost and replaced with fibrinoid material. This condition,

along with increase in blood flow and the associated haemodynamic forces convert

the entire length of the spiral arteries from small muscular arteries to dilated, tortuous

uteroplacental vessels. At term these changes can be seen at the distal portion of the

radial arteries. In all, approximately 100-150 converted spiral arteries supply the

placental bed. There is increase in flow from 100ml/min-800ml/min.

Abnormal development of uteroplacental circulation in the presence of

preeclampsia and IUGR

According to Brosen et al48, Robertson et al49 and Khong et al50 a lack of

endovascular infiltration by trophoblast into the myometrial portion of the placental

bed spiral arteries is a consistent finding in the presence of preeclampsia. Classically

it is held that second wave of endovascular trophoblastic invasion that proceeds in

20
myometrial segments of the spiral arteries from about 15 weeks does not occur in

patients who will develop fetal growth restriction or pre-eclampsia. Lack of

physiological conversion is not only apparent in the myometrial segments of spiral

arteries, but also in the decidual parts of some of the vessels so that a proportion of

spiral arteries completely fail to undergo trophoblastic invasion and physiological

changes. Since unconverted vessels retain ‗high resistance / low capacitance

properties, the effect on maternal blood supply to the placenta may be dramatically

low. These may manifest as impaired growth of the baby or high BP with proteinuria

i.e. pre-eclampsia with its complications.

Fig 5: Difference between normal and preeclamptic pregnancies regarding

theextent of physiological changes in the uteroplacental arteries

Uteroplacental Circulation – Physiological Changes During Pregnancy51

Non-pregnant uterus

Characteristics shape of these waveforms shows a steep systolic slope, an early

diastolic notch and a small diastolic flow. The waveform remains essentially high

resistance although the waveform changes in the menstrual cycle with more flow in

the luteal phase.

21
 Uterine artery impedance varies according to the phase of ovarian cycle.

Kurjaket al.199352 observed in 150 women that average RI (Resistance Index) during

the proliferative phase was 0.88+/-0.04 (2SD). The RI starts to drop one day prior to

ovulation reached a nadir of 0.84+/-0.04 (2SD) on day 18 and remained at this level

for remainder of the cycle.

Pregnancy changes were described by Campbell et al, 198353. As pregnancy

evolves the diastolic phase augments the gradient of the deceleration phase reduces,

and the notch disappears in the first term in 27% of pregnancies, although its

disappearance is sometimes not simultaneous in both uterine arteries.

Flow changes in the uterine arteries are expressed as modification in Doppler

indices. At the onset of pregnancy, these indices show few differences compared with

their values in the absence of pregnancy. From the 12th-26th weeks of pregnancy

there is a progressive lowering of these indices. In addition, the indices are lower in

the artery homolateral to the implantation site. The difference between the arteries is

more evident from the 8th week and they disappear after the 24th week. The findings

are clearly related to the histological changes in the spiral arteries caused by the

trophoblastic invasion of these vessels.

There is a gradual disappearance of notch 20% of these patients retain notch

by 20 weeks and >9% by 24 weeks. Hence by 24-26 weeks the notch disappears and

so does the difference between S/D ratio of placental and non-placental sites.

Uterine artery Doppler in normal pregnancy

Uterine artery flow velocity waveforms recorded in an early pregnancy have

the diastolic notch which represents increased impedance to blood flow during early

22
diastole in normal pregnancy. The early diastolic notch persist until approximately 26

weeks of gestations during which second wave of trophoblastic invasion would have

completed resulting in vessels of minimal resistant, no elastic property and vigorous

diastolic flow.

Persistence of notch indicates severe hypertensive disease. The presence of

notch during 3rd trimester is associated with a significantly increase rate of fetal

growth restriction.

Uterine Artery in PIH Patient

Impedance to blood flow in the uterine artery may increase in pregnancy

complicated by hypertension as shown by Fleschier et al when uterine artery S/D ratio

more than 2.6 during third trimester the birth weight at delivery was lower than

normal.

Impaired uterine artery flow velocity can be identified by persistent abnormal

index, persistent notch and significant difference between the indices in the two

vessels. It was demonstrated when the difference between right and left uterine artery

S/D ratio is more than one the incidence of adverse fetal outcome is high. Difference

right and left artery S/D ratio is probably due to unilateral placentation.

Uterine artery Doppler in predicting PIH and IUGR

Campbell et al54 (1983) was first to report uterine artery Doppler velocimetry.

They showed that compared to pregnancies with normal uterine artery waveforms,

pregnancies with abnormal uterine artery Doppler waveforms were associated with

23
more proteinuric hypertension required more anti-hypertensive therapy, and resulted

in lower birth weights in younger gestational ages at birth. Thus the capability of this

potentially safe non-invasive prospective means of analyzing uterine artery blood

flow during pregnancy was realized and set-off a wave of interest and research over

the ensuing years.

Gerard Albaiges55 et al (2000) conducted a study on one-stage screening for

pregnancy complications with Doppler assessment of uterine arteries. Women who

had highest risk are those with bilateral notches and high mean pulsatile index. They

have 40% chances of developing pre-eclampsia, 45% of developing infant birth

weight less than 10% percentile.

Harrington et al56 (1991) reported on two mid pregnancies screening studies

on 925 patients in predicting subsequent development of PIH and IUGR. There was a

significant association between abnormal flow (RI higher than the 95th percentile)

and subsequent development of hypertension and IUGR. There was no significant

association with non proteinuric hypertension. To improve the sensitivity, color flow

imaging and use of the Diastolic notch as well as elevated RI was introduced. In this

study 2437 were patient studied at 20 weeks gestation, 16% had abnormal waveforms.

5.4% persisted at 24th week and 4.6% persisted at 26 weeks of gestation. Therefore

the high sensitivity of 76% at 20 weeks was maintained at 24 and 26 weeks while the

specificity improved from 86% to 97%. These screening studies may play important

role in targeting population at risk.

Kurdie et al57 (1988) examined the uterine arteries by Doppler in 946

unselected women at 19-21 weeks. In 12.4 of cases, there were bilateral notches and

in this group, the odds ratio for developing pre-eclampsia was 12.8, and for patients

24
requiring delivery before 37 weeks, it was 52.6 When the uterine artery Doppler

studies were normal, the odds ratio for developing pre-eclampsia was 0.11 and for

fetal growth restriction (birth weight <5th percentile for gestational age), it was 0.3 in

women with bilateral notches and a mean resistance index > 0.55, the sensitivity and

for the complications requiring delivery before 37 weeks, the sensitivities were 88 for

both. It was concluded that women with normal uterine Doppler study at 20 weeks

constitute a group that have a low risk of developing obstetric complication related to

uteroplacental insufficiency, whereas women with bilateral notches have an increased

risk of subsequent development of such complications in particular to those requiring

delivery before term. Consequently the results of Doppler studies of uterine arteries at

time of routine 20 weeks anomaly scan may be of use in determining the type and

level of antenatal care that is offered to these women.

Antsaklis et al58 (2000) revised the issue of gestational age at screening and

placental localization in a low risk population of nulliparous women. They reported

that using the definition, ―any notch‖ and for pre-eclampsia requiring delivery before

34 weeks, sensitivity over 90% . Also screening at20 rather than 24 weeks has higher

sensitivity 81% and lower specificity 84%. The authors specified that for a fully

lateral placenta, the sensitivity of unilateral or bilateral notches for pre-eclampsia

reduced significantly from 88% for a mid-position placenta to 33 for a lateralized

placenta. Also that in case of lateralized placenta the flow through the placental side

uterine artery is more important a determinant of uteroplacental flow. They concluded

that screening is best performed at 24 weeks.

Bower et al59 (1993) conducted a cross sectional study on 2430 women

between 18-22 weeks to obtain velocity waveforms from both uterine arteries. Their

outcome measures were intrauterine death, ante partum hemorrhage and three
25
different degrees of severity of pre-eclampsia and growth retardation. They found that

by including an early diastolic notch, the prediction of pre-eclampsia improved

markedly. They concluded that this simple test can be performed at a routine visit and

a group of women can be identified for further assessment and possible therapeutic

interventions.

Schulman et al60 (1989) Screening on 255 women in general obstetric

population found 9 positive results. 7 of these were true positives for hypertensive

syndromes, but the most significant disease was seen when there was a co-existing

abnormal flow velocity in the umbilical artery.

C. J. Bhat et al61 (2003) studied role of Doppler in PIH. In this study, out of

100 PIH cases 56% had abnormal S/D Ratio in umbilical artery and / or uterine artery,

60% of these patients delivered IUGR babies. In patients with absent end diastolic

velocity and reversed end diastolic velocity perinatal mortality was 50% and 50% had

IUGR babies. The results of abnormal umbilical artery were more significant than

uterine artery in predicting perinatal outcome.

Zimmerman et al62 (1997) studied 175 women at high risk and 172 patients at

low risk for pregnancy- induced hypertension and fetal growth restriction in a

prospective cross sectional trial. Their parameters were waveforms from uterine

arteries, uteroplacental arteries in region of placental implantation and umbilical

artery at 21-24 weeks. They defined as abnormal, persistent notches in the main stem

uterine arteries and elevated resistance indices of > 0.68 in the uterine arteries and >

0.38 in the utero placental arteries. The incidence of proteinuric pregnancy induced

hypertension (PPIH) and intra uterine growth restriction was recorded as main

outcome measure. They found that abnormal outcomes were 58.3 when Doppler was

26
abnormal and 8.3 if Doppler results were normal. They concluded that combination of

all parameters was superior to a single parameter and a bilateral notch superior to

unilateral. Pathological Doppler velocimetry was a powerful predictor of PIH and/or

fetal growth restriction in high-risk pregnancies.

In a study by Murlidhar V Pai63 (2001), total of 111 singleton pregnant women

were subjected to Doppler, between 18-22 and 24-28 weeks. The RI of the uterine at

both the intervals was calculated. RI at both the intervals in women with normal

pregnancy was correlated with the outcome variables, namely development of

proteinuric hypertension and / or IUGR. It was found that RI were significantly higher

in women who developed PIH and had IUGR babies, hence it was concluded that

abnormal RI may herald the development of PIH and/or IUGR and may be used as a

screening test.

North et al37 (1994) used Doppler ultrasound to obtain uterine artery

waveforms at 19-24 weeks gestation in 458 nulliparous. This method identified 51%

of women with subsequent preeclampsia or SGA infants and had a positive predictive

value of 29%. The test detected women with severe disease requiring delivery before

37 weeks with a sensitivity of 83 % and specificity of 88%. A normal test predicted

an uncomplicated pregnancy. He concluded that, although abnormal uterine artery

Doppler is associated with an increased risk of preeclampsia and FGR the positive

predictive values do not support its introduction as a routine screening test in

nulliparas women. Various parameters of the flow waveforms have been studied as

predictors of abnormal perinatal outcome.

Bewley et al64 (1991) studied uteroplacental blood flow and found that

pregnancies with high AVRI values had higher prevalence of protenuric hypertension,

27
placental abruption, and small for gestational age babies and fetal loss. When AVRI

was more than 95th centile, the overall risk of pregnancy complication was 67% and

the risk of severe complication was 25%. However the sensitivity was only 13% and

21% respectively. They concluded that Doppler screening thus detects abnormal

outcomes; the predictive values do not justify its introduction as routine test.

Kofinas et al65 (1992) evaluated uterine artery resistance in 123 pregnant

women. In patients with unilateral placentas (n= 67) the placental uterine artery was

found to be a better predictor of poor pregnancy outcome than the non-placental

artery and the mean of the two arteries. Unilateral placental location was associated

with longer stays in neonatal intensive care units and more perinatal deaths.

The time of examining the uterine flow has been studied extensively.

Harrington et al66 (1996) reported a reduction in the incidence of notching

from 16 at 18-22 weeks to 8.9 at 24 weeks and suggested an abnormal Doppler should

be definitively diagnosed at 22-27 weeks to reduce false positive rate.

Oliviere Irion et al67 (1998) carried out a two stage screening of the uterine

arteries at 18 and 26 weeks of gestation. At 26 weeks all the abnormalities of the

studied Doppler indices were significantly associated with pre-eclampsia and low

birth weight for gestation. The performance of the Doppler measurements performed

at 18 weeks was poor and concluded that uterine artery Doppler velocimetry

waveform analysis does not qualify as a reliable screening test for pre-eclampsia or

low birth weight for gestation in low risk pregnancies but may be useful in selected

high risk populations.

28
 Gupta Shashi et al12 conducted using transvaginal colour doppler imaging,

concluded that uterine artery doppler study between 12 to 16 week of gestational age

is good screening method of women at high risk of developing complications related

to uteroplacental insufficiency.

Katie M Groom et al67 described the changes in mean uterine artery resistance

index and bilateral uterine artery notches between 20 and 24 weeks of gestation and

its outcome was done, concluded that 20 weeks is the most appropriate gestation in

second trimester to perform uterine artery doppler.

W Plusencia et al68 evaluated by the performance of screening for pre-

eclampsia by uterine artery Doppler pulsatility index at 11+0 to 13+6 weeks of

gestation was done and it was concluded that the effective screening can be achieved

by the doppler measurement of uterine artery, Pulsatility Index (PI) at 11+0 to 13+6

and 21+0 to 24 weeks of gestational age.

O.Gomez et al69 studied the role of uterine artery doppler in early prediction of

hypertensive disorder and associated complications and concluded that pregnancies

with an increased risk of developing hypertensive disorder and related complications

already have an abnormally increased uterine artery PI in early pregnancy of 11-14

weeks trans-vaginal (TV) doppler study.

A.M. Martin et al13 assessed the value of uterine artery doppler at 11-14 weeks

of gestational age in the identification of women at risk of developing pre-eclampsia

and fetal growth restriction and concluded that high proportion of women can be

screened effectively for pre-eclampsia at 11-14 weeks by doppler study of uterine

artery .

29
 A.T.Papageorguiou et al70 determined the value of trans-vaginal colour

doppler assessment of the uterine arteries at 23 weeks of gestation in prediction of

subsequent development of pre- eclampsia and fetal growth restriction and concluded

that at one stage colour doppler screening at 23 weeks is this most effective tool.

K.Harrington et al71 studied trans-vaginal uterine and umbilical artery doppler

at 10 - 12 weeks of gestation and measuring early diastolic notch, resistance index,

pulsatility index and subsequent development of pre- eclampsia and IUGR,

concluded that abnormal doppler value leads to Pregnancy Induced Hypertension

(PIH), premature delivery and Small for Gestational Age (SGA) baby.

Fig 6: Uterine artery waveform with early diastolic notch

30
 METHODOLOGY

An observational study was done over a period of one year among women

attending the out-patient department for antenatal care at S.D.M. Medical College

and Hospital Dharwad, Karnataka, during the period of November 2011 to October

2012.

Inclusion criteria

All pregnant women between 12 to 16 weeks of gestational age with

singleton pregnancy.

Exclusion criteria

Multiple gestation.

Patient with congenital anomaly of fetus, chronic hypertension, renal

disease, cardiac disease.

Sample size: 100

Study design: An observational study.

When above criteria were met study group was subjected to Doppler study after

dating and screening scan at 12-16 week of gestation.

Procedure

After assessment of inclusion and exclusion criteria, 100 antenatal women of

12 to 16 weeks of singleton pregnancy were selected for the study in the department

of Obstetrics and Gynaecology of S.D.M. Medical College Dharwad. Women

booking for antenatal care were examined and investigated. After an written informed

consent, the women were subjected to transvaginal ultrasound for dating and
31
screening scan. Women were placed in the dorsal position with knee flexed, a trans-

vaginal ultrasound scan was done and doppler assessment of uterine circulation for

uterine artery indices using Philips USG machine with 7.5 Mhz transvaginal

curvilinear transducer. After initial assessment, the cervix was identified. Uterine

artery is located on one side by placement of probe in that fornix and colour flow

mapping was done. The utero placental circulation was measured by various uterine

artery doppler indices, Resistance Index (RI) and Pulsatility Index (PI). Increased

resistance to flow in the uterine artery is associated with the appearance of diastolic

notch and increase in all these indices. Same procedure was repeated on the opposite

side. The whole procedure was completed within 10 minutes. These women were

again rescanned at 24-26 weeks of gestation by transabdominal USG HP image point

color Doppler machine with convex probe 3.5 MHz. With ultrasonography fetal

biometry and morphology scan was done then Doppler mode was switched on. Patient

is put in recumbent position with transducer in the longitudinal plane. The external

iliac artery is visualized at pelvic side wall with color Doppler. The transducer is then

angled medially towards the uterine artery, where they cross the external iliac artery.

The flow velocity waveforms on the right and left uterine arteries were taken when 3

or 4 waves of equal height were seen, the image was frozen and measurements were

taken either by trace method/ manually/automatic trace . Then Doppler indices were

obtained directly from the machine and further followed up clinically for development

of pre-eclampsia. The utero placental circulation were measured by various uterine

artery doppler indices i.e. resistance index (RI) and pulsatility index (PI). Increased

resistance to flow in the uterine artery is associated with the appearance of diastolic

notch and increase in all these indices

32
These patients were followed up till delivery and details of pregnancy events, delivery

and neonatal outcome were noted. The abnormal pregnancy outcomes considered are

preeclampsia. Perinatal outcomes are considered are IUFD, Apgar at 5 minutes, birth

weight and NICU admission.

Method of statistical analysis

Statistical analysis was done using descriptive statistical methods like mean,

percentages and proportions. Chi-square test was used to find the association between

two attributes and unpaired t-test was used to find the association between two

variables. A p-value of less than 0.05 was cosidered to be statistically significant.

33
 RESULTS

After assessment of inclusion and exclusion criteria, 100 antenatal women of 12 to 16

weeks of singleton pregnancy were selected for the study in the OPD of Obstetrics

and Gynaecology of S.D.M. Medical College Dharwad.. After an informed consent,

the women were subjected to transvaginal ultrasound for dating and screening scan,

doppler assessment of uterine circulation for uterine artery indices were done. These

women were again rescanned at 24-26 weeks of gestation by transabdominal USG

and further followed up clinically for development of preeclampsia.

34
 TABLE 1
Age distribution in years
Age in years Frequency Percent
Less than 20 46 46.0
21-30 52 52.0
More than 30 2 2.0
Total 100 100.0

GRAPH 1
Age distribution in years

Age Distribution
60

50

40

30
Age Distribution
20

10

0
<20 21-30 >30

About 52% of women are in the age group 21-30 years and 46% belong to teenage
group.

35
 TABLE 2
Educational status
Schooling Frequency Percentage
Primary 11 11.0
a
Secondary 49 49.0
l
Intermediate 38 38.0
i
Graduate 2 2.0
d
Total 100 100.0

GRAPH 2

Educational status

Education
60

50

40

30
EDUCATION
20

10

0
Primary Secondary Intermediate Graduates

About 49% of women have got secondary education, 38% of intermediates,11%

studied till primary schooling and 2% were graduates.

36
 TABLE 3

Socioeconomic status
Class Frequency Percentage

2 3 3.0

3 45 45.0

4 32 32.0

5 20 20.0

Total 100 100.0

GRAPH 3

Socioeconomic status

Socioeconomic status
50
45
40
35
30
25
20 Socioeconomic status
15
10
5
0
2 3 4 5

About 45%, 32%, 20% of women belong to class 3,class 4, class 5 socioeconomic

status respectively, as per Modified B. G. Prasad classification - 2012.

37
 TABLE 4

Parity distribution
Gravida Frequency Percentage

1 54 54.0

2 37 37.0

3 6 6.0

4 3 3.0
Total 100 100.0

GRAPH 4

Parity distribution

Gravida
60

50

40

30

20

10

0
1 2 3 4

About 54% of women were primigravida.

38
 TABLE 5

Statistical analysis of gesstation age at scan

Gestation No of Minimum Maximum Mean Standard

age at subjects deviation
scan

GA1 100 12+4 16+0 14+1 0.835

GA2 100 23+1 25+6 24+6 0.555

GRAPH 5

Statistical analysis of gestation age at scan

30
24.6
25

20

14.1
15

10

0
GA1 GA2

Mean Gestation age at scan

Mean gestation age at transvaginal USG is 14+1 and at transabdominal USG is 24+6
weeks.

39
 TABLE 6

Systolic blood pressure in study group in third trimester

BP in mmHg Frequency Percentage

<130 77 77.0

130-139 1 1.0

140-149 12 12.0

>150 10 10.0

TOTAL 100 100.0

GRAPH 6

Systolic blood pressure in study group in third trimester

Systolic blood pressure

90
80
70
60
50
40 Systolic blood pressure
30
20
10
0
<130 130-140 140-150 >150

About 78% are normotensive and 22% are associated with hypertensive disorders of

pregnancy.

40
 TABLE 7

Diastolic blood pressure in study group in third trimester

BP in mmHg Frequency Percentage

<80 57 57.0

80-89 21 21.0

90-100 22 22.0

Total 100 100.0

GRAPH 7

Diastolic blood pressure in study group in third trimester

Diastolic blood pressure

60

50

40

30
Diastolic blood pressure
20

10

0
<80 80-90 90-100

About 78% are normotensive and 22% are associated with hypertensive disorders of

pregnancy.

41
 TABLE 8
Uterine artery Doppler diastolic notching at 12-16 weeks

Notching at 12-16 Frequency Percentage

weeks
Present 35 35.0
Absent 65 65.0
Total 100 100.0

GRAPH 8

Uterine artery Doppler diastolic notching at 12-16 weeks

Uterine artery notching at 12-16 weeks

70

60

50

40
Uterine artery notching at 12-
30 16 weeks

20

10

0
PRESENT ABSENT

Uterine artery Doppler notching at 12-16 weeks is seen in 35% of women.

42
 TABLE 9

Uterine artery Doppler diastolic notching at 24-26 weeks

Notching at 24- Frequency Percent

26 weeks
1 16 16.0
2 84 84.0
Total 100 100.0

GRAPH 9

Uterine artery Doppler diastolic notching at 24-26 weeks

Uterine artery doppler diastolic notching at 24-26 weeks

90
80
70
60 Uterine artery
doppler diastolic
50
notching at 24-26
40 weeks

30
20
10
0
PRESENT ABSENT

Uterine artery Doppler notching at 24-26 weeks is seen in 16% of women.

43
 TABLE 10

Association of uterine artery diastolic notch with development of

preeclampsia
Notch at Preeclampsia P value Notch at Preeclampsia P value
12-16 24-26
No % No %
week week

Present 12 34.3 Present 12 75

Significant
Highly
significant
Absent 10 15.4 Absent 10 11.9

N1: X2=4.736, df=1, p=0.042 N2: X2 =31.180, df=1,p<0.0001

GRAPH 10

Association of uterine artery diastolic notch with development of

preeclampsia

80

70

60

50

40 N1

30 N2

20

10

0
Present Absent

Uterine artery Doppler notching at 12-16 weeks is seen in 34.3% of preeclamptic

women which is statistically significant (p< 0.042).

Uterine artery Doppler notching at 24-26 weeks is seen in 75% of preeclamptic

women which is statistically significant (p< 0.0001).

44
 TABLE 11

Resistance Index and Pulsatility Index in study group

Doppler Number Minimum Maximum Mean Standard

indices deviation

RI1 100
0.51 0.68 0.5757 0.03641
RI2 100
0.42 0.66 0.4728 0.06264
PI1 100
0.84 1.08 0.8957 0.06155
PI2 100
0.57 1.06 0.6478 0.13898

GRAPH 11

Mean Resistance Index and Pulsatility Index in study group

1
0.89
0.9
0.8
0.7 0.64
0.6 0.57

0.5 0.47

0.4
0.3
0.2
0.1
0
RI1 RI2 PI1 PI2

Mean uterine artery doppler indices

Mean RI and PI are 0.57 and 0.89 respectively at 12-16 weeks.

Mean RI and PI are 0.47 and 0.64 respectively at 24-26 weeks

45
 TABLE 12

Association of Resistance index at 12-16 week and 24-26 week of gestation

Uterine artery Doppler indices in preeclamptic and in normal pregnant women

RESISTANCE INDEX

Resistance In preeclamptic women In non preeclamptic

indices women

Gestation Mean Standard deviation Mean Standard

age deviation

At 12-16 0.6073 0.05382 0.5668 0.02344

week

t=5.169, df=98, p<0.0001

Resistance In preeclamptic women In non preeclamptic

indices women

Gestation Mean Standard Mean Standard

age deviation deviation

At 24-26 0.5382 0.09194 0.4544 0.03425

week

t=6.642, df=98, p<0.0001

46
 GRAPH 12

Association of mean RI1 and RI2 in preeclamptic and non preeclamptic women

0.7
0.6073
0.6 0.5668
0.5382

0.5 0.4544

0.4

0.3

0.2

0.1

0
Mean RI1 Mean RI2

Preeclampsia Non preeclampsia

Above table and graph shows that in preeclampsia mean RI at 12-16 weeks is 0.6073

and at 24-26 weeks is 0.5382, which is statistically significant(p<0.0001) as compared

to non preeclamptic women.

47
 TABLE 13

Association of uterine artery notch and RI at 12-16 week of gestation,in

preeclamptic and in non preeclamptic women.

RI at 12- Uterine artery notching(n=35)

16 week
Preeclamptic women(n=12) Non preeclamptic women(n=23)

Number Percent Number Percent

0.55-0.59 1 8.33 21 91.3

0.6-0.64 5 41.66 1 4.34

0.65-0.69 6 50 1 4.34

X2=23.26, df=2, p<0.0001

GRAPH 13

Association of uterine artery notch and RI at 12-16 week of gestation in

preeclamptic and in non preeclamptic women.

100.00%
90.00%
80.00%
70.00%
60.00%
50.00% Preeclamptic women
40.00% Non preeclamptic women
30.00%
20.00%
10.00%
0.00%
0.55-0.59 0.60-0.64 0.65-0.69

Above table and graph shows that 50% of preeclamptic women have RI between

0.65-0.69 and 41.66% have RI between 0.60-0.64 which is statistically

significant(p<0.0001) as compared to non preeclamptic women.

48
 TABLE 14

Comparison of uterine artery notch alone and uterine artery notch with

RI>0.65 with development of preeclampsia

Abnormal uterine artery Preeclampsia

waveform at 12-16 weeks
Number Percentage

Uterine artery 12 34.28%

notch(n=35)

Notch+ RI >0.65 6 85.71%

(n=7)

GRAPH 14

Comparison of uterine artery notch alone and uterine artery notch with RI>0.65

with development of preeclampsia

Percentage of Preeclampsia detected

90.00%
80.00%
70.00%
60.00%
50.00%
40.00% Percentage of Preeclampsia
detected
30.00%
20.00%
10.00%
0.00%
Notch Notch with RI>0.65

When uterine artery notch alone is considered 34.28% developed preeclampsia.

Both notch+ RI>0.65 considered together 85.71% developed preeclampsia.

49
 TABLE 15

Association of at 12-16 week and 24-26 week of gestation Uterine artery

Doppler pulsatility index in preeclamptic and in normal pregnant women

PULSATILITY INDEX

Pulsatility In preeclamptic women In non preeclamptic

indices (n=22) women (n=78)

Gestation Mean Standard deviation Mean Standard

age deviation

At 12-16 0.9573 0.09051 0.8783 0.03532

week

t=6.252, df=98, p<0.0001

Pulsatility In preeclamptic women (n=22) In non preeclamptic

indices women (n=78)

Gestation Mean Standard Mean Standard

age deviation deviation

At 24-26 0.7968 0.20721 0.6058 0.0706

week

t=6.909, df=98, p<0.0001

50
 GRAPH 15

Association of at 12-16 week and 24-26 week of gestation Uterine artery

Doppler pulsatility index in preeclamptic and in normal pregnant women

1.2

1 0.9573
0.8783
0.7968
0.8
0.6058
0.6

0.4

0.2

0
PI1 PI2

Preeclampsia Nonpreeclampsia

Above table and graph shows that in preeclampsia mean PI at 12-16 weeks is 0.9573

and at 24-26 weeks is 0.7968, which is statistically significant(p<0.0001) as compared

to non preeclamptic women.

51
 TABLE 16

Role uterine artery Doppler in predicting preeclampsia at 12-16 weeks

Study Sensitivity Specificity PPV NPV

variables

Uterine 34.29% 84.62% 54.55% 70.51%

artery notch

Notch + 85.71% 84.62% 37.5% 98.21%

RI>0.65

GRAPH 16

Role uterine artery Doppler in predicting preeclampsia at 12-16 weeks

120.00%

100.00%

80.00%
Sensitivity
60.00% Specificity
PPV
40.00% NPV

20.00%

0.00%
Notch only Notch+ RI1>0.65

Uterine artery notching at 12-16 weeks gestation has 84.62% specificity, 70.51%

NPV.

When notch and RI >0.65 taken together increases sensitivity by 85.71% and NPV by

98.25%.

52
 TABLE 17

Gestation age at delivery in weeks

Number of Minimum Maximum Mean Standard

subjects deviation

100 30.60 41.10 38.1660 0.18598

Mean gestation age at delivery is 38+1 weeks.

53
 TABLE 18

Gestation age at delivery in preeclamptic women

Gestation age in weeks Frequency (n=22) Percentage

at delivery

>38 2 9.09

36-38 14 63.63

34-36 4 18.18

32-34 2 9.09

GRAPH 17

Gestation age at delivery in preeclamptic women

Gestation age at delivery

70

60

50

40

30 Gestation age at delivery

20

10

0
>38 36-38 34-36 32-34

In preeclampsia 63.63% women delivered between 36-38 weeks of gestation age,

18.18% delivered between 34-36 weeks and 9.09% delivered between 32-34 week

54
 TABLE 19

MODE OF DELIVERY

Mode of delivery Frequency Percentage

FTND 75 75.0

PTVD 9 9.0

LSCS 16 16.0

TOTAL 100 100.0

GRAPH 18

MODE OF DELIVERY

Mode of delivery
80

70

60

50

40
Mode of delivery
30

20

10

0
FTND PTVD LSCS

About 75% had FTVD,9% had PTVD and 16 % had LSCS.

In preeclampsia about 59.09% had FTVD, 31.81% had PTVD and 9.09% had LSCS.

55
 TABLE 20

Descriptive statistics for birth weight, APGAR score, NICU stay

Neonatal Standard
N Minimum Maximum Mean
outcome deviation

Birth weight in
kg 100 1.20 3.6 2.840 0.484339

0.957
Ap1 100 0 9 7.75

Ap5 100 0 9 8.76 0.965

NICU Stay in
100 0 16 0.85 2.585
days

GRAPH 19

Descriptive statistics for birth weight, APGAR score, NICU stay

10
8.76
9
7.75
8
7
6
5
4
2.8
3
2
0.85
1
0
Mean Bt Wt Mean AP1 Mean AP5 Mean NICU stay

Mean value

Mean birth weight is 2.8kg .

Mean APGAR at 1 min is 7.75.

Mean APGAR at 5 min is 8.76. Mean NICU stay is 85 hours

56
 TABLE 21

Neonatal outcome in preeclampsia

Variables Frequency (n=22) Percentage

NICU Adm 8 36.66

IUGR 4 18.18

IUFD 1 4.5

GRAPH 20

Neonatal outcome in preeclampsia

Neonatal outcome
40.00%

35.00%

30.00%

25.00%

20.00%
Neonatal outcome
15.00%

10.00%

5.00%

0.00%
NICU admission IUGR IUFD

In Preeclampsia 18.18% IUGR, 4.5% IUFD noted and 36.66% of neonate required

NICU admission.

57
 DISCUSSION
In our observational study done over a period of one year among 100 women

attending the outpatient department for antenatal care at S.D.M. Medical College and

Hospital analyzed for Doppler changes of uterine artery at 12-16 weeks by

transvaginal ultrasound and repeated at 24- 26 weeks by transabdominal ultrasound.

These patients were followed up till delivery and details of pregnancy events, delivery

and neonatal outcome were noted.

Uterine artery Doppler assessment for presence of diastolic notch, RI, PI

values, both at 12-16 weeks and 24-26 weeks are studied. Out of 100 women studied

22% women developed preeclampsia thus prevalence is similar to Gupta Shashi et

al12(20%) and high prevalence compared to that quoted by Bewley et al77 in 1991

(4.6%) and Iron et al80 in 1998 (4%). Among 100 women 35% had notching at 12-16

weeks, 16% had persistence of notching at 24-26 weeks which is more as compared

to Harrington K et al71 described preeclampsia in 15.16% of the women with B/L

notch at 12-16 weeks of gestation.

Mean RI in our study is 0.57 at 12-16 weeks and 0.47 at 24-26 weeks. In

41.66% of preeclamptic women mean RI at 12-16 week is 0.6073 and at 24-26 week

is 0.5382 which is statistically significant as compared to non preeclamptic group (

p<0.0001) and hence this will help in prediction preeclampsia when combined with

58
uterine artery notching similar to Gupta Shashi et al12 where mean RI in 37.5% was

0.60.

When uterine artery notch at 12-16 weeks alone is considered, 34.28% of

women developed preeclampsia. Detection rate increased upto 85.71% when RI>0.65

is also included along with uterine artery Doppler diastolic notching. Hence

Prediction of preeclampsia has increased when B/L uterine artery notching is

combined with RI of uterine artery Doppler. Thus the sensitivity increased from

34.29% to 85.71% when RI>0.65 is included with notch which is similarly described

by Gupta Shashi et al12.

Mean PI in our study is 0.89 at 12-16 weeks and 0.64 at 24-26 weeks. In

preeclampsia mean PI at 12-16 weeks is 0.9573 and at 24-26 weeks is 0.7968, which

is statistically significant(p<0.0001) as compared to non preeclamptic women. Hence

this will help in prediction preeclampsia when combined with uterine artery notching

similar to O.Gomez et al69.

In our study out 100 women 35 patients had bilateral notching at 12-16 weeks

and 12 women developed preeclampsia. Hence sensitivity of bilateral uterine artery

notching is 34.29%, specificity is 84.62% positive predictive value is 54.55%, and

negative predictive value is 70.51% in prediction of preeclampsia similar to Gupta

Shashi et al12 .

59
 Mean gestation age at delivery is 38+1 week, 75% had full term vaginal

delivery and 9% had preterm vaginal delivery and 16% had Caesarean delivery, about

9 babies delivered preterm with minimum birth weight of 1.3kg and mean birth

weight is 3.6 kg, mean Apgar at 1 min is 7 and at 5 min is 8. In preeclamptic women 4

babies were associated with IUGR, IUFD in 1 preeclamptic woman. Mean duration of

NICU stay is 2 days.

Comparison of our study with previous studies for preeclampsia with uterine

artery doppler

Author Outcome Indicator Sensitivity Specificity PPV NPV

(%) (%) (%) (%)
TH
Bewley et al Preeclampsia RI>95 24 95 20 96

Bower et al Preeclampsia RI>95TH 7.5 86 12 99

+/- notch
North et al Preeclampsia RI>95TH 27 89 8 97
Chan et al Preeclampsia RI>95TH 22 97 36 94
Irion et al Preeclampsia SD>90TH + 26 88 7
notch
Kurdi et al Preeclampsia RI>95TH 62 89 11 99
Gupta et al Preeclampsia Notch + 68.7 66.6 31.43 90.5
TH
RI>95
Our study Preeclampsia Notch only 34.29 84.62 54.55 70.51
Our study Preeclampsia Notch + RI 85.71 84.62 37.5 98.21

60
Comparison of our study with previous studies, for preeclampsia with uterine

artery Doppler at 12-16 week.

Author Gestation Indicator Sensitivity Specificity PPV NPV

age at (%) (%) (%) (%)
screening
AM 11-14 PI> 95TH 27 95.4 11 98.4
Martin week
Gupta 12-16 Notch+ 68.7 66.6 31.4 90.5
Shashi week RI
O Gomez 11-14 PI 24 95 11.3 97.9
week
Our study 12-16 Notch 34.29 84.62 54.55 70.51
week only
Our study 12-16 Notch + 85.71 84.62 37.5 98.21
week RI

61
 CONCLUSION
Preeclampsia is a complex clinical syndrome involving multiorgan systems

and perinatal mortality and morbidity. The research for ideal predictive test and

preventive measure remains challenging.

In our study the mean of all uterine artery indices showing impedance to

uteroplacental circulation (RI, PI, notching) are significantly higher. This shows that

resistance to blood flow is a more important indicator than the actual blood flow.

In our study 35% of women had B/L uterine artery notching, mean RI is 0.57,

PI is 0.89 at 12-16 weeks. When uterine artery notch at 12-16 weeks alone is

considered, 34.28% of women developed preeclampsia. Detection rate increased upto

85.71% when RI>0.65 is also included along with uterine artery Doppler diastolic

notching. Uterine artery notching at 12-16 weeks gestation has 84.62% specificity,

70.51% NPV. When notch and RI >0.65 considered together sensitivity increases by

85.71% and NPV by 98.25%. Hence uterine artery Doppler study even at 12-16

weeks helps in early prediction of preeclampsia.

Uterine artery Doppler studies between 12-16 weeks also help us to categorize

our patients into low risk and high risk so that proper vigilance may be done in high

risk women.

Doppler is a non-invasive method for evaluation of feto-placental circulation without

any disturbance to human pregnancy.

The uterine artery notching, high Resistance Index and Pulsatility Index in

uterine artery Doppler waveform at 12-16 weeks has shown as best screening test for

early prediction of preeclampsia.

62
 SUMMARY

After assessment of inclusion and exclusion criteria 100 antenatal women of

12 to 16 weeks of singleton pregnancy were selected for the study. After an informed

consent women were subjected to transvaginal ultrasound for dating scan during

which uterine artery Doppler waveforms were taken . These women were again

rescanned at 24-26 weeks of gestation by transabdominal USG and further followed

up clinically for development of preeclampsia.

Uterine artery Doppler were studied in all 100 cases.

In this study 52% of the women are in the age group 21-30 years, belonged to

lower socioeconomic status, about 54% are primigravida, mean gestational age at

transvaginal USG is 14+1 and transabdominal USG at 24+6 weeks. About 22% of

women developed preeclampsia among 100 women. Uterine artery notch is seen in

35% of women at 12-16 weeks and 16% at 24-26 weeks. About 34.5% of women

with notch at 12-16 weeks and 75% women with notch at 24-26 weeks developed

preeclampsia.

In preeclamptic women mean RI at 12-16 week is 0.6073 in 41.66% of

preeclamptic women and at 24-26 week is 0.5382 which is statistically significant as

compared to non preeclamptic group ( p<0.0001) and hence this will help in

prediction preeclampsia when combined with uterine artery notching. Uterine artery

notching at 12-16 weeks gestation had 84.62% specificity, 70.51% NPV. Both notch

+ RI >0.65 when considered together increases sensitivity by 85.71% and NPV by

98.25%.

63
Mean gestation age at delivery is 38+1 week,75% had full term vaginal delivery, 9%

had preterm vaginal delivery and 16% had Cesarean delivery. About 9 babies were

delivered preterm, mean birth weight is 3.6 kg, mean Apgar at 1 min is 7 and at 5 min

is 8. In preeclamptic women 4 babies were associated with IUGR, IUFD in 1

preeclamptic woman. Mean duration of NICU stay is 2 days.

64
 BIBLIOGRAPHY

1. Report on Confidential Enquires into Maternal Deaths in the United Kingdom

1991-1993. London: HMSO; 1996:20-31.

2. Montan S.Sjoberg O-O. Svenningsen. N. Hypertension in pregnancy—fetal and

infant outcome. Clin Exp Hypertens –Hyper in Pregnancy 1987; B62: 337-348.

3. Ventura SJ, Martin JA, Curtin SC, Mathews TJ, Park MM: Births: Final data for

1998. National Vital statistics reports: Hyattsville, MD. National center Health

Statistics, 2000:48(3)

4. Berg CJ, Aftrash HK, Koonin LM, Tucker M: Pregnancy related mortality in the

United States, 1987-1990, Obstet Gynecol 1996;188:161.

5. Divon MY, HSU HW: Maternal and fetal blood flow velocity waveforms in

intrauterine growth retardation Clin Obstet Gynecol 1992;35:156.

6. Paz I, Gale R, Laor A, Danon YL, Stevenson DK, Seidmans D, The cognitive

outcome of full term small for gestational age infants at late adolescence. Obstet

Gynecol 1995;85:452.

7. Piper JM, Xenakin CMJ, McFarland M, Elliot BD, Barkers MD, Langer D: Do

growth retarded premature infants have different rates of perinatal morbidity and

mortality than appropriately grown premature infants? Obstet Gynecol 1996;87:169.

8. Minior VK, Divon MY: Fetal growth restriction at term: Myth or reality? Obstet

Gynecol 1998;92:57.

9. Ekholm E. Hemodynamic measures in prediction of pre-eclampsia. Acta Obstet

Gynecol Scand 1997; 76: 101-103.

65
10. Grunewald C. Biochemical prediction of pre-eclampsia..Acta Obstet Gynecol

Scand 1997 (Suppl 164);76:104- 107.

11. Walsh SW. Pre-eclampsia: an imbalance in placental prostacycline and

thromboxane production. Am J Obstet Gynecol 1985;152:335-340.

12. Gupta Shashi, Gupta Pradeep Kumar, Bodani Preeti ,Khamsera

Anshu.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 obset gynecol India 2009;59(6):541-546

13.A.M. Martin,R.Bindra,P.Curcio, S.Cicero and K.H.Nicolaides. Screening for

preeclampsia and fetal growth restriction by uterine artery doppler at 11-14 weeks of

gestation. Ultrasound obstet gynecol 2001;18:583-586.

14.Baker Dw (1970). Pulsed ultrasonic Doppler blood flow sensing IEEE Transsonic

Ultrasonics 1970;SU-17(3):170-185.

15. Angelsen BAJ, Kristofferson K(1979). On ultrasonic MTI measurement of

velocity profiled in blood flow IEEE Trans Biomed Eng BME 1979;26:665 –771.

16. Namekawa K, Kasai C, Tsukamoto M, Koyano A (1982). Imaging of blood flow

using autocor-relation. Ultrasound Med Biol 1982;8:138 [abstract].

17. Callaghan D.A, Rowland TC, Goldman DE (1964). Ultrasonic Doppler

observation of the fetal heart. Obstet Gynecol 1964;23:637

18. FitzGerald DE, Drumm JE (1977). Noninvasive measurement of the fetal

circulation using ultrasound : a new method. BMJ 1977; 2: 1450-1451

66
19. MaCallum WD, Olson RF, Daigle RE, Baker DW (1977). Real time analysis of

Doppler signals obtained from the fetoplacental circulation. Ultrasound Med

1977;3B:1361-1364.

20. Gill RW (1979). Pulsed Doppler with B-mode imaging for quantitative blood

flow measurements. Ultrasound Med Biol 1979;5:223-227.

21. Eik-Nes SH, Brubakk AO, Ulstein MK (1980). Measurement of human fetal

blood flow. BMJ 1980;28:283.

22. Campbell S, Diaz Recasens J Griffin DR, et al(1983). New Doppler technique for

assessing uteroplacental blood flow. Lancet 1983;1:675.

23. Chiba Y, Utsu M, Kanzaki T, Hasegawa T (1983). Changes in venous flow and

intra-tracheal flow in fetal breathing movements. Ultrasound Med Biol 1983; 11:43

24. Maulik D, Nanda NC, Saini VD (1984). Fetal Doppler echocardiography:

methods and characterization of normal and abnormal hemodynamics. Am J Cardiol

1984;53:572.

25. Arbeille P, Tranquart F, Body G, et al (1986). Evolution de la circulation

arterielle ombilicale et cerebrale du la foetus au cours de la grossesse. Prog Neonatol

1986;6:30

26. Wladimiroff JW, Tonge HN, Stewart PA (1986). Doppler ultrasound assessment

of cerebral blood flow in the human fetus. Br J Obstet Gynaecol 1986;93:471.

27. Vyas S, Nicolaides KH, Campbell S (1989). Renal artery flow-velocity

waveforms in normal and hypoxemic fetuses. Am J Obstet Gynecol 1989;161:168-

172.

67
28. Veille JC, Kanaan C (1989). Duplex Doppler ultrasonographic evaluation of the

fetal renal artery in normal and abnormal fetuses. Am J Obstet Gynecol

1989;161:1502-1507.

29. Devore GR, Hornstein J, Siassi B, Platt LD (1985). Doppler color flow mapping

in use the prenatal diagnosis in the human fetus Echocardiography. 1985;2:551-557.

30. Maulik D, Nanda NC, Hsiung MC, Young BJ (1986). Doppler color flow

mapping of the fetal heart. Angiology 1986;37:628-632.

31. Taylor KJW, Burns PN, Wells PNT, Conway DI, Hull MGR (1985). Ultrasound

Doppler flow studies of the ovarian and uterine arteries. Br J Obstet Gynaecol

1985;92:240-246.

32. Atkinson P, Woodcock JP (1982).Doppler ultrasound.Academic press, London.

33. Gill RW . Doppler ultrasound Physical aspects, Semin Perinatol 1987;11:292.

34. Reid JM, Spencer MP. Ultrasonic Doppler technique for imaging blood vessels.

Science 1972;176:1235.

35. Carroll BA, von RammOT. Fundamentals of current Doppler technology.

Ultrasound Obstet Gynaecol 1988;6:275.

36 Maulik D, Yarlagadda P (1987). In vitro Validation of Doppler waveform indices.

D Maulik, D McNellis (eds). Perinatology Press, Ithaca, Ny, 1987;257.

37. North RA, Ferrier CL long D, Townend K, Kincaid-smith F. Utreine artery

Doppler flow velocity waveforms in the second trimester for the prediction of pre-

eclampsia and fetal growth retardation. Obstet Gynecol 1994;83:378-86.

68
38. Low JA. The current status of maternal and fetal blood flow velocimetry. Am J

Obstet Gynecol 1991;164:1049.

39. F Gary Cunningham, Normal F gnat, Kenneth J.Leneno, Larry C. Gils trap. John

C. Hauth Katherine D. Wenstrom Williams Obstetrics, 21st edition, 567,65,743,764,

1132,1136.

40. Porcelot L. Applications cliniques de I examen Doppler transcutaneIn

.Perommeau P, ed. Velocimetric ultrasonoic Doppler. Paris. INSERM, 1974; 213-240.

41. Maulik D, Yarlagadda P young blood JP, Willoughby L. Components of

variability of umbilical artetrial Doppler velocimetry, A prospective analysis. Am J,

obstetGynecol 1989; 160:1406.

42.Merritt CRB, Kremakau FW, Hobbins JC. Diagnostic ultrasound. Bioeffects and

safety. Ultrasound Obstet Gynecol 1992;2:366.

43. Miller MW,Ziskin MC. Biological consequences of hyperthermia. Ultrasound

Med Biol 1990;15:707.

44. Itskovitz, J, Lindenbaum Es, Brandes JM (1980). Arterial anastomisis in the

pregnant human uterus. Obstet Gynecol 1980;55:67-71.

45. Usha Krishna, DK Tank, Shirish Daftary. Pregnancy at risk current concepts. 4th

ed,2001;257-285.

46. Battaglia FC, Lubchenco Lo. A practical classification of newborn infants by

weight and gestational age. J Pediatr 1967;71:159.

47. Seeds JW, Peng T. Imapaired growth and risk of fetal death is the tenth percentile

the appropriate standard ? Am J Obstet Gynecol 1998;178:658.

69
48. Brosens IA, Robertson WB, Dixon HG (1972). The role of spiral arteries in the

pathogenesis of preeclampsia. Obstet Gynecol Annu 1972;1:117-191.

49. Robertson WB, Brosens I, Dixon G (1975). Uteropcental vascular pathology. Eur

J Obstet Gynecol Reprot Biol 1975;5: 47-65.

50. Khong TY, De Wol F, Robertson WB, et al (1986) Inadequate maternal vascular

response to placentation in pregnancies complicated by preeclampsia and by small-for

gestational age infants. Br J Obstet Gynecol 1986;93:1049-1059.

51. Kevin Harrington and Stuart Campbell. The uterine circulation in pregnancy,

chapter 4 A colour atlas of Doppler ultrasonography in obstetrics.

52. Kujrak. A, Seeding, D,funduk-kurjak, B;Shalan, H; Predanic, M; Socic, A

Transvaginal color Doppler in the assessment of the uteroplacental circulation in

normal early pregnancy. – J Perinat Med. 1993;21:25-34.

53. Steet CV, Campbell S, Pampigline J, Kingland C, Mason BA, Collins Wp. (1990).

Transvaginal color flow imaging of the uterine arteries during the ovarian and

menstrual cycles. Hum Reprod 1990;5:391-99.

54.Campbell S, et al. New Doppler technique for assessing uteroplacentald blood

flow. Lancet 1983;1:675-77.

55. Albaiges G, Missfelder.-Lobos H, Lees C, Parra M, Nicolaides K H. One Stage

Screening for pregnancy complications by Color Doppler Assessment of Uterine

arteries at 23-weeks gestation. Ultrasound Obstet Gynaecol 2000;96:4.

70
56. Harrington KF, et al. Doppler velocimetry studies of the uterine artery in the early

prediction of pre-eclampsia and intra-uterine growth retardation. Eur J Obstet

Gynecol Reprod Biol 1991;42: S14.

57. Kurdi W, Campbell S, Aquilina J, England P, Harrington K. The role of color

Doppler imaging of the uterine arteries at 20 weeks gestation in stratifying antenatal

care. Ultrasound Obstet Gynecol 1988;12:339-345.

58.Antsaklis A, Daskalakis G, Tzortzis E, Michalas S. Effect of gestational age with

placental location on the prediction of pre-eclampsia by uterine artery Doppler

velocimetry in low risk nulliparous women. Ultrasound Obstet Gynecol 2000;16:635-

639.

59.Bower S, Bewlysusan, Campbell S. Improved prediction of pre –eclampsia by two

stage screening of uterine arteries using the early diastole notch and color Doppler

imaging. Obstet Gynecol 1993;82:78-83.

60. Schulman H, Winter D, Farmakides G, et al. Pregnancy surveillance with uterine

umbilical Doppler velocimetry. Am J Obstet Gynecol 1989;160:192-196.

61. C.J Bhatt, J.Arora, MS Shah, Role of Colour Doppler in pregnancy induced

hypertension ( A study of 100 cases). Ind J Radil Image 2003;13(4):417-420.

62. Zimmermann P, Eirio V, Koskinen J, Kujanscu E, Ranta T. Doppler assessment

of uterine and uteroplacental circulation in the second trimester in pregnancies at high

risk for pre –eclampsia and / or fetal growth restriction: comparisons and correlation

between different Doppler parameters. Ultrasound Obstet Gynecol 1997 9(5):330-8.

63.Muralidhar VP. Uterine Artery Doppler Velocimetry in Women with Normal

Pregnancy PIH and IUGR. Ultrasound Obstet Gynecol 2001;11.

71
64. Bewley Susan, Cooper Derek, Campblell S. Doppler investigations of

uteroplacental blood flow resistance in the second trimester: a screening study for pre

–eclampsia and intrauterine growth retardation. Br J Obstetrics and Gynecology

1991;98:871-879.

65.Kofinas AD, et al. The effect of placental location on uterine artery flow velocity

waveforms. Am J Obstet Gynecol 1988;159:1504.

66. Harrington K, Cooper P, Lees C, Hechek, Campbell S. Doppler unilateral of

uterine arteries, the importance of bilateral notching in the prediction of preeclampsia,

placental abruption or delivery of small for gestational age baby, Ultrasound Obst

Gynae 1996;7:182-188.

67.Oliver Irion, Jacques Masse, Jean-Claude Forest , Jean –Marie Moutquin.

Prediction of pre-eclampsia, low birth weight for gestation and prematurity by uterine

artery blood flow velocity waveforms analysis in low risk nulliparous women. Br J

Obstetrics and Gynecology. 1998;105:402-425.

67.Katie MG, Robyn A, North, Peter RS, Eliza H.Y.Chan, Rennae S. Taylor, Gustaaf

A.Dekker.et,al. Patterns Of change in uterine artery doppler studies between 20 and

24 weeks of gestation and pregnancy outcome. The American college of obsteticians

and Gynoecologist published 2009;113(2)332-338.

68.W.Plusencia, N.Maiz, L.Poon, C.YU and K.H.Nicolaidesl. Uterine artery doppler

at 11+0 to 13+6 weeks and 21+0 to 24+6 weeks in prediction of pre-eclampsia.

Ultrasound obstet Gynecol 2008;32:138-146.

69.O.Gomez,M.Martinez,F.Figueras,M.Delrio,V.Borobio,B.Puerto,,et al. Uterine

artery doppler at 11-14 weeks of gestation to screen for hypertensive disorders and

72
associated complications in an unselected population. Ultrasound obstet Gynecol

2005;26:490-494.

70.A.T.Papageorguiou, C.K.H.Yu, R.Bindra, G.Pandis and K.H.Nicolaides.

Multicentre screening for pre-eclampsia and fetal growth restriction by transvaginal

uterine artery doppler at 23 weeks of gestation. Ultrasound obstet Gynecol

2001;18:441-449.

71.K.Harrington,C.Goldfrad,R.G.Carpenter and S.Campbell. Transvaginal uterine and

umblical artery doppler examination of 12 to 16 weeks and the subsequent

developmnet of pre –eclampsia and intrauterine growth restriction. Ultrasound obstet

Gynecol 1997;9: 94-100.

73
 ANNEXURES

CASE PROFORMA.

Name of the Husband name

patient

Age : Age

Education Education

Occupation Occupation

O.P. NO. Address and

ph. No.

HISTORY

First trimester UPT done at

Scan done

Folic acid tablet

H/o excessive vomitting

Second trimester Quickening at

Injection t.t.

Anomaly scan

Fe and Ca tablet

Symptoms of PIH

Others

Third trimester Symptoms of pih

others

obstetrics history

Married life:

74
Consangunity :G ; P; L ; D; A;

Details of previous pregnancy :

Sl.NO DATE/YEAR ANC TYPE OF PLACE OF SEX/WT REMARKS

OF DELIVERY DELIVERY
DELIVERY

Past HT D T Epileps Astham RH Surger Allerg Blood

histor N M B y a D y y transfusio
y n

Famil HT D T Astham Multiple pregnancies

y N M B a
histor
y

HB ULTRASOUND

URINE Date

HIV Gestation age

Hbs Ag Single/multi

VDRL Presentation

GST/RBS Liquor

GTT Placenta

75
Others EDD

AGA

Doppler

Uterine artery
notching

RI

PI

Delivery Notes :

Date/Time of Delivery :

Onset of labour : spontaneous/induced

Indication of Induction

Type Of Delivery : FTVD/PTVD/Forceps/Vaccum/LSCS

LSCS : Emergency/Elective

Indication of LSCS

Baby Notes : Live Born/FSB/MSB/Abortus

Sex : M/F

Weight :

Malformations

Condition of the time of Discharge :

76
 CONSENT FORM

Consent for Study : Role of uterine artery Doppler at 12-16 weeks of gestation age in

prediction of pre-eclampsia and its outcome , a case control study.

I, the undersigned Mrs._____________________________________ giving consent

to include me in the study conducted by Dr.AmbikaPatil. I have been explained

regarding the study method and the effects and side effects associated with Doppler

ultra sonography.

My questions regarding the risks involved have been answered in satisfactory

manner.

All the above parts have been explained to me in language I understand and

hereby give my informed written consent.

Date andTime :

Signature of the Patient Signature of Doctor

Name of the Patient

IP/OP No.

77
 KEY TO MASTER CHART
Edu – Educational status.

SES- Socioeconomic status.

G- Gravida

P- Para

L- Living

A-Abortion

GA1- Gestation age at transvaginal uterine artery Doppler study

GA2- Gestation age at transabdominal uterine artery Doppler study

FH- Family history

SBP- Systolic blood pressure

DBP- Diastolic blood pressure

N1- Uterine artery notch at 12-16 week gestation

N2- Uterine artery notch at 24-26 week gestation

PI1- Pulsatility index at 12-16 week gestation

PI2- Pulsatility index at 24-26 week gestation

RI1- Resistance index at 12-16 week gestation

RI2- Resistance index at 24-26 week gestation

FTND- Full term normal delivery

Ap1- APGAR score at 1 min

Ap5- APGAR scpre at 5 min

Bt Wt- Birth weight

NICU adm- Neonatal intensive care unit admission

78
 MASTER CHART
SL NO NAME Age Edu SES G P L A GA1 GA2 FH SBP DBP N1 N2 RI1 RI2 PI1 PI2 PE GA at del Mode of delivery Ap1 Ap5 Bt Wt NICU adm Stay in NICU IUGR 1UFD
1 Vijaylaxmi 25 10 3 1 0 0 0 13+4 25+6 0 120 74 - - 0.56 0.44 0.88 0.6 - 39+1 FTND 8 9 2.8 NO NO - -
2 parvati 24 12 4 2 0 0 1 13+4 24+0 0 144 96 + + 0.64 0.62 1.04 0.98 + 35+2 PTVD 7 8 1.8 YES 4 - -
3 Vijaylaxmi 20 8 5 1 0 0 0 13+6 24+4 0 118 72 - - 0.56 0.42 0.88 0.62 - 37+2 FTND 8 9 3 NO NO - -
4 shaila 34 5 5 1 0 0 0 13+0 25+1 0 150 90 + + 0.54 0.46 0.86 0.59 + 39+3 FTND 8 9 3.1 NO NO - -
5 laxmi 20 7 5 2 1 1 0 14+1 25+0 0 106 88 - - 0.55 0.45 0.89 0.57 - 38+1 FTND 8 9 2.8 NO NO - -
6 savita 20 9 5 1 0 0 0 15+1 24+2 1 154 96 + + 0.68 0.66 1.06 1.02 + 33+2 PTVD 7 8 1.4 YES 14 + -
7 sridevi 24 10 4 3 1 1 1 14+2 25+0 0 146 90 - - 0.52 0.46 0.87 0.6 + 37+6 FTND 8 9 3.4 NO NO - -
8 shweta 20 12 3 4 2 1 1 13+1 25+6 0 118 72 - - 0.56 0.44 0.88 0.61 - 38+1 FTND 8 9 2.75 YES 1 - -
9 roopa 23 11 3 1 0 0 0 13+3 24+6 0 110 76 - - 0.56 0.42 0.86 0.59 - 30+6 PTVD 9 9 3 NO NO - -
10 pooja 23 12 3 2 1 1 0 14+4 24+2 0 142 98 + + 0.68 0.62 1.08 1.04 - 37+2 FTND 8 9 2.1 NO NO - -
11 sahana 19 10 4 2 0 0 1 14+2 25+4 0 128 86 - - 0.57 0.45 0.88 0.61 - 41+1 LSCS 8 9 2.9 NO NO - -
12 poornima 28 9 4 1 0 0 0 12+5 25+6 0 122 80 + - 0.58 0.44 0.89 0.58 - 39+3 FTND 9 9 3.1 NO NO - -
13 laxmi 25 10 3 1 0 0 0 13+4 24+2 0 118 78 - - 0.56 0.45 0.85 0.59 - 39+6 FTND 8 9 3.2 NO NO - -
14 sunita 23 10 3 1 0 0 0 14+2 24+6 0 116 68 + - 0.57 0.46 0.89 0.61 - 38+2 FTND 9 9 3.3 NO NO - -
15 savita 24 10 3 1 0 0 0 14+4 24+4 0 148 96 - - 0.56 0.44 0.87 0.6 + 37+2 FTND 7 9 2.6 YES 4 - -
16 mumtaz 18 10 3 2 0 0 1 15+0 24+0 0 128 66 - - 0.58 0.43 0.89 0.61 - 37+3 LSCS 8 9 2.9 NO NO - -
17 deepamala 19 10 3 1 0 0 0 14+2 25+0 0 126 72 + + 0.58 0.45 0.87 0.59 - 37+8 FTND 8 9 2.8 NO NO - -
18 mahadevi 17 10 3 1 0 0 0 15+4 25+1 0 124 74 - - 0.56 0.42 0.87 0.58 - 37+1 FTND 8 9 2.7 NO NO - -
19 jyoti 19 12 3 2 1 1 0 13+2 25+4 0 120 74 + - 0.59 0.44 0.86 0.58 - 39+2 FTND 7 9 3.2 NO NO - -
20 anupama 18 11 3 2 1 1 0 14+2 24+6 0 122 82 - - 0.56 0.45 0.84 0.59 - 38+4 LSCS 8 9 3.1 YES 2 - -
21 bhuvaneshwari 16 12 3 2 1 1 0 13+2 24+2 0 112 84 - - 0.57 0.46 0.87 0.61 - 39+3 FTND 8 9 3.6 NO NO - -
22 sujata 19 10 3 3 2 1 1 14+6 24+4 0 112 84 - - 0.58 0.5 0.88 0.62 - 40+4 FTND 8 9 3.4 NO NO - -
23 shobha 18 10 3 1 0 0 0 15+2 24+1 0 148 98 + + 0.66 0.62 1.04 0.98 + 37+4 FTND 6 8 1.8 YES 2 - -
24 poornima 18 5 5 1 0 0 0 13+6 24+5 0 120 68 - - 0.54 0.43 0.88 0.6 - 39+2 LSCS 7 8 3.3 NO NO - -
25 renuka 19 10 5 1 0 0 0 14+4 25+2 0 126 64 - - 0.55 0.44 0.87 0.59 - 40+5 FTND 7 8 3.2 NO NO - -
26 sumangala 20 9 3 2 1 1 0 13+6 25+6 1 144 94 + + 0.68 0.64 1.02 0.98 + 35+6 PTVD 8 9 1.7 YES 6 + -
27 fathima 21 8 3 1 0 0 0 15+0 24+0 0 128 76 - - 0.57 0.45 0.84 0.58 - 37+1 FTND 8 9 2.9 NO NO - -
28 laxmi 21 8 3 1 0 0 0 13+6 25+1 0 112 72 - - 0.54 0.44 0.89 0.57 - 38+2 FTND 8 9 2.6 YES 1 - -
29 sneha 18 7 5 2 1 1 0 14+6 24+4 0 118 72 - - 0.6 0.42 0.88 0.59 - 39+1 FTND 8 9 2.8 NO NO - -
30 devamma 19 12 3 1 0 0 0 15+2 24+1 1 116 76 + + 0.58 0.47 0.87 0.6 - 40+4 FTND 8 9 2.9 YES 1 - -
31 roopa 19 11 3 1 0 0 0 12+6 24+0 0 112 78 - - 0.56 0.46 0.88 0.61 - 38+3 FTND 8 9 2.6 NO NO - -
32 sridevi 18 12 4 1 0 0 0 14+3 24+6 0 116 82 - - 0.57 0.44 0.87 0.61 - 37+2 FTND 8 9 3.2 NO NO - -
33 uma 18 10 4 2 1 1 0 13+6 24+2 1 150 96 + + 0.68 0.66 1.02 0.98 + 34+5 PTVD 7 8 1.4 YES 16 + -
34 sujata 18 10 4 1 0 0 0 16+0 25+1 0 126 62 - - 0.58 0.45 0.88 0.57 - 38+3 FTND 8 9 3.1 NO NO - -
35 varna 20 10 4 1 0 0 0 15+2 24+6 1 122 74 + - 0.59 0.5 0.88 0.58 - 37+5 FTND 8 9 2.9 NO NO - -
36 poornima 21 12 4 2 1 1 0 14+2 24+1 0 108 62 - - 0.56 0.49 0.86 0.59 - 38+5 FTND 8 9 2.8 NO NO - -
37 kavya 19 11 4 3 1 1 1 16+0 25+2 0 118 78 - - 0.58 0.45 0.89 0.58 - 39+1 FTND 8 9 3.3 NO NO - -
38 gangamma 18 12 4 1 0 0 0 15+2 25+4 1 112 76 + - 0.55 0.43 0.88 0.57 - 40+1 LSCS 8 9 3.25 NO NO - -
39 nirmala 19 12 4 2 1 1 0 13+6 25+1 1 154 96 - - 0.56 0.44 0.87 0.6 + 37+6 FTND 8 9 2.8 NO - -
40 suvarna 19 10 4 1 0 0 0 14+2 24+2 0 112 70 - - 0.58 0.46 0.88 0.61 - 38+4 FTND 8 9 3.1 YES 1 - -
41 roopa 18 10 5 2 0 0 1 13+2 24+6 0 150 90 + + 0.64 0.62 1.08 1.06 + 35+2 PTVD 6 7 1.6 YES 10 - -
42 rekha 18 10 5 3 0 0 2 14+2 24+1 0 120 88 - - 0.54 0.45 0.86 0.61 - 40+2 LSCS 8 9 3.6 NO NO - -
43 vinuta 18 10 4 2 0 0 1 13+2 25+1 1 122 82 + - 0.56 0.44 0.89 0.6 - 40+1 FTND 7 8 2.9 NO NO - -
44 sangeeta 19 10 4 1 0 0 0 14+2 25+2 0 122 66 - - 0.57 0.48 0.87 0.59 - 39+2 FTND 8 9 2.8 NO NO - -
45 annapurna 18 11 4 1 0 0 0 15+2 25+4 0 156 92 - - 0.57 0.48 0.89 0.58 + 37+2 FTND 8 9 2.6 NO NO - -
46 asha 19 12 4 1 0 0 0 16+0 25+0 0 112 72 + - 0.54 0.44 0.88 0.59 - 38+6 LSCS 7 8 2.8 YES 1 - -
47 reshma 19 12 4 2 0 0 1 14+0 24+0 0 120 78 - - 0.56 0.46 0.86 0.59 - 39+5 FTND 8 9 2.9 NO NO - -
48 laxmi 18 12 4 2 0 0 1 13+2 25+2 0 128 78 - - 0.55 0.43 0.87 0.6 - 40+2 LSCS 8 9 3.1 NO NO - -
49 prabha 18 10 4 1 0 0 14+0 24+1 0 148 90 + + 0.68 0.62 1.02 0.98 + 37+2 FTND 8 9 2.4 NO NO - -
50 ashwini 19 10 4 1 0 0 0 13+6 24+6 0 112 88 - - 0.6 0.51 0.88 0.58 - 39+2 FTND 8 9 2.9 NO NO - -
51 shakuntala 19 10 4 2 1 1 0 13+6 24+4 0 146 90 - - 0.56 0.44 0.88 0.6 + 36+4 PTVD 7 9 1.8 YES 8 - -
52 ambika 19 8 3 1 0 0 0 12+4 25+0 0 110 82 + - 0.58 0.46 0.87 0.61 - 38+6 FTND 8 9 2.5 NO NO - -
53 chetana 26 7 3 1 0 0 0 13+0 24+4 0 118 72 - - 0.56 0.42 0.88 0.62 - 37+2 FTND 8 9 3 NO NO - -
54 prabhavati 25 7 4 2 1 1 0 13+6 24+0 0 108 76 - - 0.54 0.46 0.86 0.59 - 39+3 FTND 8 9 3.1 NO NO - -
55 annapurna 21 10 5 2 1 1 0 15+0 24+6 0 106 88 + - 0.55 0.45 0.89 0.57 - 38+1 FTND 8 9 2.8 NO NO - -
56 ayesha 21 12 3 1 0 0 0 15+2 25+0 0 110 84 - - 0.51 0.45 0.88 0.58 - 40+3 FTND 8 9 3 NO NO - -
57 shruti 20 BA 2 1 0 0 0 15+4 25+6 0 116 70 - - 0.52 0.46 0.87 0.6 - 37+6 FTND 8 9 3.4 NO NO - -
58 tejashwini 33 10 4 1 0 0 0 14+0 24+3 0 118 72 + - 0.56 0.44 0.88 0.61 - 38+1 FTND 8 9 2.75 YES 1 - -
59 menaka 24 11 4 1 0 0 0 15+1 25+0 0 110 76 - - 0.56 0.42 0.86 0.59 - 30+6 PTVD 9 9 3 NO NO - -
60 kavya 23 5 5 3 2 2 0 13+0 25+4 0 152 96 - - 0.55 0.43 0.85 0.6 + 38+1 FTND 8 9 2.6 NO NO - -
61 laxmi 28 6 5 1 0 0 0 12+5 25+0 0 128 86 - - 0.57 0.45 0.88 0.61 - 41+1 LSCS 8 9 2.9 NO NO - -
62 geeta 20 10 3 1 0 0 0 14+5 24+6 0 148 90 + + 0.64 0.6 1.08 1.02 + 37+2 FTND 8 9 2.2 NO NO - -
63 rukmini 21 12 3 2 1 1 1 14+0 24+2 0 118 78 - - 0.56 0.45 0.85 0.59 - 39+6 FTND 8 9 3.2 NO NO - -
64 sumangala 28 12 3 2 0 0 0 13+2 24+0 0 116 68 + - 0.57 0.46 0.89 0.61 - 38+2 FTND 9 9 3.3 NO NO - -
65 salma 27 12 3 1 0 0 0 13+3 24+3 0 114 64 - - 0.56 0.44 0.87 0.6 - 38+6 FTND 7 9 3.4 YES 4 - -
66 bibiayesha 24 10 3 2 1 0 0 15+0 25+5 0 150 90 - - 0.58 0.43 0.89 0.61 + 37+3 LSCS 8 9 2.2 NO NO - -
67 tasneem 23 12 3 1 0 0 0 15+4 25+6 1 126 72 + - 0.58 0.45 0.87 0.59 - 37+8 FTND 8 9 2.8 NO NO - -
68 deepa 25 6 5 3 2 2 0 14+4 24+1 0 124 74 - - 0.56 0.42 0.87 0.58 - 37+1 FTND 8 9 2.7 NO NO - -
69 netra 28 9 5 2 1 1 0 13+6 24+3 0 120 74 + - 0.59 0.44 0.86 0.58 - 39+2 FTND 7 9 3.2 NO NO - -
70 megha 23 10 5 1 0 0 0 15+1 24+2 0 122 82 - - 0.56 0.45 0.84 0.59 - 38+4 LSCS 8 9 3.1 YES 2 - -
71 laxmi 22 12 4 1 0 0 0 13+6 23+6 0 112 84 - - 0.57 0.46 0.87 0.61 - 39+3 FTND 8 9 3.6 NO NO - -
72 renuka 25 1 5 1 0 0 0 13+4 25+1 0 144 94 - - 0.58 0.5 0.88 0.62 + 37+2 FTND 8 9 2.8 NO NO - -
73 preeti 20 12 3 2 1 1 0 14+1 24+3 0 100 72 + - 0.6 0.51 0.84 0.62 - 39+1 FTND 6 8 3.5 YES 2 - -
74 pooja 28 12 3 2 0 0 1 15+2 25+2 0 120 68 - - 0.54 0.43 0.88 0.6 - 39+2 LSCS 7 8 3.3 NO NO - -
75 manjula 27 12 2 4 2 2 1 15+4 24+1 0 126 64 - - 0.55 0.44 0.87 0.59 - 40+5 FTND 7 8 3.2 NO NO - -
76 anassuya 24 12 3 2 1 1 0 13+6 25+0 0 124 74 + - 0.56 0.43 0.89 0.59 - 38+3 FTND 8 9 2.8 NO NO - -
77 kavita 23 10 5 1 0 0 0 13+3 24+5 0 156 94 - - 0.57 0.45 0.84 0.58 + 37+1 FTND 8 9 2.6 NO NO - -
 78 asma 25 9 5 1 0 0 0 14+1 24+1 0 112 72 + - 0.54 0.44 0.89 0.57 - 38+2 FTND 8 9 2.6 YES 1- -
79 shilpa 28 5 5 2 1 1 0 15+2 24+2 0 118 72 - - 0.6 0.42 0.88 0.59 - 39+1 FTND 8 9 2.8 NO NO - -
80 pratiksha 23 8 5 2 0 0 1 13+6 25+2 0 116 76 - - 0.58 0.47 0.87 0.6 - 40+4 FTND 8 9 2.9 YES 1- -
81 aarti 22 10 3 2 1 1 0 13+4 25+0 0 112 78 + - 0.56 0.46 0.88 0.61 - 38+3 FTND 8 9 2.6 NO NO - -
82 lalita 25 12 3 2 1 1 0 13+6 24+3 0 116 82 - - 0.57 0.44 0.87 0.61 - 37+2 FTND 8 9 3.2 NO NO - -
83 kavita 27 12 3 1 0 0 0 13+3 24+1 0 146 90 + + 0.66 0.64 1.02 0.98 + 37+3 FTND 8 9 2.6 NO NO - -
84 madhumati 23 12 3 2 0 0 1 14+2 25+1 0 126 62 - - 0.58 0.45 0.88 0.57 - 38+3 FTND 8 9 3.1 NO NO - -
85 roopa 25 12 3 2 1 1 0 14+1 24+2 0 122 74 + - 0.59 0.5 0.88 0.58 - 37+5 FTND 8 9 2.9 NO NO - -
86 vimala 22 10 3 1 0 0 0 15+1 24+6 0 108 62 - - 0.56 0.49 0.86 0.59 - 38+5 FTND 8 9 2.8 NO NO - -
87 nirmala 25 10 3 1 0 0 0 15+0 23+6 0 118 78 - - 0.58 0.45 0.89 0.58 - 39+1 FTND 8 9 3.3 NO NO - -
88 vanita 26 10 3 2 1 1 0 13+6 23+1 0 158 90 - - 0.55 0.43 0.88 0.57 + 37+2 LSCS 8 9 3.25 NO NO - -
89 amita 25 10 3 1 0 0 0 13+4 23+5 1 116 74 + - 0.56 0.44 0.87 0.6 - 37+6 FTND 8 9 3.4 NO NO - -
90 pushpa 22 10 3 1 0 0 0 13+5 24+4 0 112 70 - - 0.58 0.46 0.88 0.61 - 38+4 FTND 8 9 3.1 YES 1- -
91 suma 20 10 3 1 0 0 0 14+2 24+1 0 148 94 + + 0.64 0.6 1.06 1.02 + 37+4 FTND 8 9 2.4 NO NO - -
92 soumya 20 10 3 1 0 0 0 13+5 24+2 0 120 88 - - 0.54 0.45 0.86 0.61 - 40+2 LSCS 8 9 3.6 NO NO - -
93 aruna 30 12 4 4 1 1 2 14+4 24+1 0 122 82 - - 0.56 0.44 0.89 0.6 - 40+1 FTND 7 8 2.9 NO NO - -
94 padmavati 23 12 4 1 0 0 0 14+1 25+1 0 122 66 - - 0.57 0.48 0.87 0.59 - 39+2 FTND 8 9 2.8 NO NO - -
95 shruti 20 BSc 2 1 0 0 0 13+2 24+5 1 116 74 + + 0.64 0.62 1.08 1.02 - 39+4 FTND 8 9 2.7 NO NO - -
96 shilpa 20 12 3 2 1 1 0 15+2 24+2 0 112 72 - - 0.54 0.44 0.88 0.59 - 38+6 LSCS 7 8 2.8 YES 1- -
97 mahalaxmi 26 10 4 1 0 0 0 14+6 25+2 0 120 78 - - 0.56 0.46 0.86 0.59 - 39+5 FTND 8 9 2.9 NO NO - -
98 ratna 25 12 4 2 0 0 1 13+5 25+0 0 128 78 - - 0.55 0.43 0.87 0.6 - 40+2 LSCS 8 9 3.1 NO NO - -
99 savita 25 10 4 2 1 1 0 14+4 24+0 0 144 96 + + 0.62 0.6 1.04 0.98 + 32+2 PTVD 0 0 1.2 NO NO + +
100 manjula 28 12 4 1 0 0 0 14+1 24+2 0 112 88 - - 0.56 0.43 0.86 0.6 - 39+2 FTND 8 9 2.9 NO NO - -