Obstetrikte Dopplerin Tanısal ve Klinik Değeri
Özet
Doppler ultrasonografi, damarlardaki kan akışını tespit ederek obstetrikte preeklampsi, fetal büyüme geriliği, fetal anemi ve fetal ölüm gibi hastalıkların tanı ve takibinde klinik değer taşıyan önemli bir yöntemdir. Rezistans indeksi (RI), sistol/diyastol (S/D) oranı ve Pulsatilite indeksi (PI) akım direncini belirleyen temel parametrelerdir. Obstetrikte sürekli dalgalı, renkli akım, power ve puls Doppler olmak üzere dört farklı mod kullanılır. Klinik kullanım maternal uterin arter ile fetal arteryel ve venöz Doppler olarak iki kısımda ele alınır. Uterin arter Doppler incelemesinde direnç artışı veya diyastolik çentiklenme bulunması, preeklampsi ve gelişim geriliğinin erken tespiti için kritik bir göstergedir. Fetal değerlendirmede ise umbilikal arter, orta serebral arter (MCA) ve duktus venozus temel damarlardır. Umbilikal arterde diyastol sonu akım kaybı veya ters akım izlenmesi irreversibl plasental hasara işaret eder. MCA Doppler ölçümlerinde peak sistolik hızın (PSV) 1.5 MoM üzerinde olması non-invazif yolla fetal anemi tanısı koyulmasını sağlar ve kan transfüzyon zamanlamasını belirler. Ayrıca MCA ile umbilikal arter PI değerlerinin oranı olan serebroplasental oran (CPR), olumsuz gebelik sonuçlarını öngörmede etkindir. Sonuç olarak Doppler teknolojisi, fetal iyilik halinin ve anomalilerin değerlendirilmesinde vazgeçilmez bir klinik rehberdir.
Doppler ultrasonography is an important method that detects blood flow in vessels and carries clinical value in the diagnosis and monitoring of conditions such as preeclampsia, fetal growth restriction, fetal anemia, and fetal death in obstetrics. Resistance index (RI), systole/diastole (S/D) ratio, and Pulsatilitiy index (PI) are the main parameters used to determine flow resistance. Four different modes are utilized in obstetrics: continuous wave, color flow, power, and pulsed Doppler. Clinical application is examined in two parts: maternal uterine artery Doppler and fetal arterial and venous Doppler. The presence of increased resistance or diastolic notching in uterine artery Doppler examination is a critical indicator for the early detection of preeclampsia and growth restriction. In fetal evaluation, the umbilical artery, middle cerebral artery (MCA), and ductus venosus are the primary vessels assessed. Observing end-diastolic flow loss or reverse flow in the umbilical artery indicates irreversible placental damage. In MCA Doppler measurements, a peak systolic velocity (PSV) above 1.5 MoM enables the non-invasive diagnosis of fetal anemia and determines the timing for blood transfusion. Additionally, the cerebroplacental ratio (CPR), which is the ratio of MCA to umbilical artery PI values, is effective in predicting adverse pregnancy outcomes. In conclusion, Doppler technology serves as an indispensable clinical guide in the evaluation of fetal well-being and anomalies.
Referanslar
Meyberg G C, Sohn C, Grünbaum S. The clinical value of Doppler ultrasound in obstetrics. Geburtshilfe Frauenheilkd. 1996 Aug;56(8):401-6.
Crispi F, Comas M, Hernandez-Andrade E, et al. Does preeclampsia influence fetal cardiovascular function in early-onset intrauterine growth restriction? Ultrasound Obstet Gynecol 2009; 34:660-5.
Deane C, Lees C (2000) Doppler obstetric ultrasound: a graphical display of output patterns. Ultrasound Obstet Gynecol 15,418-423.
Nicolaides K, Giuseppe R, Hecher K. Doppler in Obstetrics. ISUOG educational series.p.22-23.
Giordano R, Cacciatore A, Romano M. Uterine artery Doppler Flow Studies in Obstetric Practice. J Prenat Med 2010; 4:59-62.
Toal M, Keating S, Machin G, et al. Determinants of adverse perinatal outcome in high-risc women with abnormal uterine artery Doppler images. Am J Obstet Gynecol 2008; 198:330. e 1-7.
Kofinas AD, Penry M, Greiss FC Jr. The effect of placental location on uterine artery flow velocity wave forms. Am J Obstet Gynecol 1988; 159:1504-8. Giancarlo Mari. Doppler ultrasonography in obstetrics:from the diagnosis of fetal anemia to the treatment of intrauterine growth-restricted fetuses. Am J Obstet Gynecol 2009; 613: e1-8.
Harrington K, Thomson MO, Carpenter RG. Doppler fetal circulation in pregnancies complicated by pre-eclampsia or delivery of a small for gestational age baby: 2. Longitudinal analysis. Br J Obstet Gynaecol 1999; 106: 453-66.
Mari G, Hanif F, Kruger M. Sequence of cardiovascular changes in IUGR in pregnancies with and without preeclampsia. Prenat Diagn 2008; 28:377-83.
Piper J, Langer O, Xenadis EM. Perinatal outcome in growth-restricted fetuses: do hypertensive and normotensive pregnancies differ? Obstet Gynecol 1996; 88:194-9.
Figueras F, Gratacos E. An integrated approach to fetal growth restriction. Best Pract Res Clin Obstet Gynaecol 2017; 38:48-58.
Michael Y.Divon. Umbilical artery Doppler velocimetry: clinical utility in high-risk pregnancies. Am J Obstet Gynecol 1996; 174:10-4.
De Vore GR. The importance of the cerebroplacental ratio in the evaluation of fetal well-being in SGA and AGA fetuses. Am J Obstet Gynecol 2015; 213:5-15.
Schenone M, Mari G. The MCA Doppler and its role in the evaluation of fetal anemia and fetal growth restriction. Clin Perinatol. 2011 Mar;38(1):83-102.
Vollgraff C A, De Boer M, Heymans M, et al. Prognostic accuracy of cerebroplacental ratio and middle cerebral artery Doppler for adverse perinatal outcome:systematic review and meta-analysis. Ultrasound Obstet Gynecol.2018 Mar;51(3):313-322.
Seravalli V, Miller JL, Block D. Ductus venosus Doppler in the assessment of fetal cardiovascular health: an updated practical approach. Acta Obstet Gynecol Scand 2016; 95:635-44.
Ferrazzi E, Lees C, Acharya G. The controversial role of the ductus venosus in hypoxic human fetuses. Acta Obstet Gynecol Scand. 2019;98(7):823-829.
Oepkes D, Seaward G, Vandenbussche F, et al. Doppler Ultrasonography versus Amniocentesis to Predict Fetal Anemia. N Engl J Med 2006;355:156-64.
Mari G, Deter RL, Carpenter RL et al. (2000) Non-invasive diagnosis by Doppler ultrasonography of fetal anaemia due to maternal red-cell alloimmünization. N Engl J Med 432(1), 9-14.
I Fantasia et al. Fetal major cardiac defects and placental dysfunction at 11-13 weeks’ gestation. Ultrasound Obstet Gynecol 2018 Feb;51(2):194-198.
