Comparison of umbilical-artery velocimetry and cardiotocography for surveillance of small-for-gestational-age fetuses. Randomized comparison of routine vs highly selective use of Doppler ultrasound and biophysical scoring to investigate high risk pregnancies. Comparison of the modified biophysical profile to a "new" biophysical profile incorporating the middle cerebral artery to umbilical artery velocity flow systolic/diastolic ratio. Randomised controlled trial of cardiotocography versus umbilical artery Doppler in the management of small for gestational age fetuses. [Umbilical Doppler velocimetry in prolonged pregnancies]. The Doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery Doppler ultrasound and biometry in twin pregnancy. The role of Doppler velocimetry in the management of high risk pregnancies. The effect of introduction of umbilical Doppler recordings to obstetric practice. Umbilical artery flow velocity waveforms in high-risk pregnancy. Randomised controlled trial. Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial. Doppler ultrasonography in suspected intrauterine growth retardation: a randomized clinical trial. Doppler flow velocity waveform analysis in high risk pregnancies: a randomized controlled trial.
Intrauterine growth retardation is associated with an increased risk of fetal asphyxia as well as greater perinatal morbidity and mortality. Ultrasound fetometry enables detection of fetuses that are small for gestational age. Doppler velocimetry of the umbilical artery has good predictive ability for fetal distress, but it is not yet clear whether it could replace cardiotocography in antenatal surveillance of small-for-gestational-age fetuses. We have done a randomised comparison of the two methods. At four obstetric departments in Sweden, women with fetuses found to be small on ultrasound examination at 31 completed weeks of pregnancy or later were randomly assigned to antenatal surveillance with either doppler velocimetry (doppler; 214) or cardiotocography (CTG; 212). Pregnancies in the doppler group were managed according to a protocol based on blood-flow classes deriving from the semiquantitative evaluation of umbilical-artery velocity waveforms; unless the pregnancy was complicated by any other disorder, no antenatal cardiotocography was done. By comparison with the CTG group, the doppler group had fewer monitoring occasions (mean 4.1 [SD 3.1] vs 8.2 [6.2], p < 0.01), antenatal hospital admissions (68 [31.3%] vs 97 [45.8%], p < 0.01), inductions of labour (22 [10.3%] vs 46 [21.7%], p < 0.01), emergency caesarean sections for fetal distress (11 [5.1] vs 30 [14.2%], p < 0.01), and admissions to neonatal intensive care (76 [35.5%] vs 92 [43.4%], p = 0.10). The groups did not differ in gestational age at birth, birthweight, Apgar scores, or total number of caesarean deliveries. Umbilical-artery doppler velocimetry of small-for-gestational-age fetuses allows antenatal monitoring and obstetric interventions to be aimed more precisely than does cardiotocography. To compare routine versus highly selective use of Doppler ultrasound and biophysical scoring in higher risk pregnancy.
                A pragmatic randomized trial.
                St James's University Hospital, Leeds.
                500 pregnant women at high risk of intrauterine growth retardation or still birth.
                Regular monitoring with biophysical profile assessment and Doppler velocity waveform recording in umbilical and uteroplacental arteries. Results immediately available to clinicians.
                Gestational age at delivery, obstetric intervention rates and short-term neonatal morbidity.
                Risk factors were distributed very evenly between the 250 patients in the study and control groups respectively. A total of 902 biophysical profile and Doppler assessments were done in the 250 study group patients and only in 12 patients in the control group. In the study group, absent end-diastolic flow was found in only 2.7% of all 902 measurements. A persistently abnormal biophysical score was always associated with absence of end-diastolic flow. The mean gestational age at induction of labour was statistically and clinically similar in the two groups and there was no overall statistically significant difference in intervention rates between the two groups. There was a statistically significant lower frequency of depressed 5-min Apgar scores in the study group. Serious neonatal morbidity was also statistically significantly more common in the control group than in the study group.
                The use of Doppler ultrasound in higher risk pregnancies does not lead to an increase in iatrogenic preterm delivery. The total rate of positive tests on Doppler ultrasound is very low and persistently abnormal biophysical scores are unlikely to be found in patients where umbilical end-diastolic blood flow is present. Surrogate measures for fetal damage seem to be improved when clinicians have access to Doppler ultrasound assessments. The objective of this study was to determine whether the addition of the middle cerebral to umbilical artery systolic/diastolic velocity waveform ratio to the modified biophysical profile would improve perinatal outcome in patients at high risk.
                A prospective, randomized outcome study of patients referred to the perinatal laboratory for antenatal surveillance was undertaken. Six hundred sixty-five patients were randomized to two antenatal surveillance protocols: group 1, modified biophysical profile; and group 2, modified biophysical profile plus evaluation of the middle cerebral artery to umbilical artery systolic/diastolic ratio. Patients were followed up serially and neonatal outcome data including gestational age at delivery, birth weight, incidence of cesarean section delivery for fetal distress, admission to the neonatal intensive care unit, days in the neonatal intensive care unit, and the presence of significant neonatal morbidity were tabulated.
                The total population showed no statistical difference in outcome parameters between groups 1 and 2. However, a subgroup of patients evaluated for suspected uteroplacental insufficiency did show a significant reduction in caesarean section for fetal distress in group 2 patients.
                In a subgroup of patients at risk for uteroplacental insufficiency, the addition of the middle cerebral/umbilical artery ratio to an antenatal surveillance protocol should be expected to improve perinatal outcome. To compare the impact on use of resources in the management of small for gestational age babies using Doppler ultrasound versus cardiotocography.
                A randomised controlled trial.
                A large district general hospital delivering 5500 to 6000 infants each year, 30% to 35% of which are to women of Pakistani origin.
                One hundred and fifty women delivered of small for gestational age infants.
                Primary outcome measures were length of hospital inpatient stay and induction of labour rates. Secondary outcome measures included caesarean section rates and length of stay on neonatal unit.
                The use of Doppler reduced average hospital inpatient stay from 2.5 days to 1.1 days, compared with cardiotocography (P = 0.036). There was no effect on induction of labour rates or caesarean section rates. There was no significant difference in length of stay on the neonatal unit (P = 0.33). There was a reduction in monitoring frequency and fewer hospital antenatal clinic visits.
                The use of Doppler ultrasound to manage small for gestational age infants reduces the use of resources, compared with cardiotocography. One-hundred and eighty-seven single pregnancies, at full term determined accurately and confirmed by ultrasound before 17 weeks of amenorrhea and which were proceeding normally were monitored every 2 days after the expected end of term. This was done by conventional methods and in 132 cases by determining a placental resistance index (R = D/S). All the deliveries were carried out under monitoring and the infants examined by a pediatrician. The umbilical index at 280 to 300 days of gestation was found to be constant and equal to R = 0.52 +/- 0.041 (n +/- D) and the signs of fetal distress and post-maturity increased beyond term. In the first 80 pregnancies studies in this way, the determination of the value of the index R was not included in the decision-making process. Twelve of the 14 cases of fetal heart rate arrhythmia during delivery and all recorded cases of post-mature clinical signs and neonatal acidosis occurred when the index was above RI = 0.54. The next 107 pregnancies were randomly divided into two groups. In the 52 pregnancies in which the Doppler revealed an index at two consecutive determinations in excess of 0.54, this was taken to be a criterion for the induction of childbirth. In this group, some of the women gave birth earlier, without any increase in the number of Caesareans and this resulted in fewer post-mature infants.(ABSTRACT TRUNCATED AT 250 WORDS) To assess the addition value of umbilical artery Doppler ultrasound added to standard ultrasound biometry measurements in the management of twin pregnancies.
                A prospective randomised controlled multicentre trial of women with twin pregnancies.
                Tertiary level referral hospitals in Australia, New Zealand and Southeast Asia.
                Pregnant women with twin pregnancies.
                Women were randomised at 25 weeks of gestation to receive either standard ultrasound biometric assessment or standard assessment plus Doppler ultrasound umbilical artery flow velocity waveform analysis. The studies were repeated at 30 and 35 weeks unless otherwise indicated. Physicians were advised to institute close fetal surveillance in the presence of an abnormal umbilical artery Doppler study or with biometry indicators of fetal compromise.
                Standard obstetric (mode of delivery, perinatal mortality, hypertension, antenatal admissions and gestation at delivery) and neonatal (5 minute Apgar scores <5, admissions to neonatal nursery and requirements for ventilation) outcomes and statistical analysis was on intention-to-treat. There were no significant differences between the two groups with respect to demography, antenatal, peripartum and neonatal outcomes. There was no difference in the perinatal mortality rate in the no Doppler group (n = 264), which was 11/1000 live births, and the Doppler group (n = 262), which was 9/1000 live births. There were three unexplained intrauterine deaths in the no Doppler group and none in the Doppler group (OR 0.14, 95% CI 0.01-1.31). Two intrauterine deaths in the Doppler group were due to cord prolapse in labour and a fetomaternal haemorrhage, both very unlikely to be influenced by Doppler surveillance.
                In this study, close surveillance in twin pregnancy resulted in a lower than expected fetal mortality from 25 weeks of gestation in both the no Doppler and Doppler groups. The lower rate of unexplained fetal death in the no Doppler group was not significantly different from the Doppler group. To determine whether knowledge of the result of Doppler velocimetry of the umbilical artery is beneficial to the management of a high risk pregnancy.
                Randomised controlled trial. The trial was of the management type, designed to assess benefit accruing from additional information supplied by Doppler velocimetry.
                Tygerberg Hospital, Cape Town, South Africa. The hospital serves a population from the lower socio-economic groups.
                Women with pregnancies 28 or more weeks gestation with hypertensive diseases and/or suspected small for gestational age fetuses were referred for Doppler velocimetry. From this population, three subsets were formed: 1. those with fetuses with absent end-diastolic velocities (20 fetuses); 2. those with hypertension but with fetuses with end-diastolic velocities (89 fetuses); and 3. those with fetuses suspected of being small for gestational age but with end-diastolic velocities (104 fetuses).
                Doppler velocimetry on all subjects. The study group consisted of 10 cases with absent end-diastolic velocities, 47 cases with hypertensive diseases with end-diastolic velocities and 51 cases with suspected small for gestational age fetuses but with end-diastolic velocities in which the result was revealed to the clinician. The control group consisted of 10, 42 and 53 cases, respectively, in which the Doppler results were not revealed. All other routine investigations (sonar and antenatal fetal heart rate monitoring) were available to the clinicians. Standard management protocols were followed in all groups.
                Perinatal mortality and morbidity, antenatal hospitalisation, maternal intervention, admission to the neonatal intensive care unit and hospitalisation until discharge from the neonatal wards.
                In the study and control groups the gestational age at entry to the study, maternal age, parity and various complications were not significantly different. In the subset with absent end-diastolic velocities, there was one neonatal death in the study group, but in the control group there were six deaths, five intrauterine and one perinatally related infant death (P = 0.029). Because of this significant finding, the study was stopped. There were no differences in outcome in the subset where there was hypertensive disease with end-diastolic velocities between the study and control groups. In the subset in which small for gestational age fetuses were suspected, but in which end-diastolic velocities were present, the women in the study group had significantly fewer days in hospital before delivery (P < 0.001) and tended to have fewer maternal interventions (study group = 27%, control group = 43%; P = 0.07; odds ratio (OR) 0.49, 95% confidence limits (CL) 0.2 and 1.25) and caesarean sections (study group = 13%, control group = 27%; P = 0.08; OR 0.43, 95% CL 0.14 and 1.32). The infants of the study group in this subset also spent significantly less time in the neonatal wards (P = 0.029). To assess the effect on obstetric practice of clinician access to umbilical artery Doppler ultrasound results.
                Randomised controlled trial.
                A large teaching hospital.
                Two thousand two hundred and eighty-nine pregnancies defined as being at risk by referral for Doppler or fetal monitoring.
                Continuous wave Doppler studies of umbilical artery. Results immediately available to clinicians.
                Fetal outcome: perinatal mortality, Apgar score and admission to the neonatal unit. Obstetric intervention: admission to hospital, induction of labour and caesarean section. Use of of fetal well being: cardiotocography, biophysical profile and ultrasound biometry.
                The treatment and control groups were comparable in age, parity, gestation at point of entry and risk features. There were no overall differences in perinatal outcome, obstetric intervention or use of fetal monitoring. Examination of a subset recruited only because of hypertension or suspected intrauterine growth retardation (n = 754) similarly showed no difference attributable to group randomisation. Comparison of only those pregnancies retrospectively defined as low risk and high risk showed more use of cardiotocography in the high risk group with access to Doppler (P = 0.007) but no difference in the low risk group.
                Doppler umbilical artery recording has been shown to perform well in prediction power of antenatal fetal compromise. What has been examined in this study is the response of clinicians to the test. The results suggest that obstetricians do not use the test to modify their risk assessment, and, therefore, the need for fetal monitoring in particular pregnancies. There is a real need for accumulation of information from very large data sets, particularly in the prediction power of Doppler for antenatal fetal compromise from apparently chronic utero-placental cause to guide use of monitoring resources. If simply added to existing fetal monitoring techniques in a hospital where these are widely used, then umbilical artery Doppler recordings may at present simply involve extra resources of staff and expenses, without benefit. 300 patients at high fetal risk (mean gestational age 34 wk) were randomised to a group for antenatal doppler umbilical artery waveform studies and a control group. The timing of delivery was similar in the control and doppler-report-available groups overall. However, in the report group obstetricians allowed the pregnancies of those not selected for elective delivery to continue longer. There was no difference in the rates for elective delivery (induction of labour or caesarean section) in the two groups, whereas among those who went into labour (induced or spontaneous) emergency caesarean section was more frequent in the control group (23%) than in the report group (13%). Fetal distress in labour was also more common in the control group. Babies from the control group spent longer in neonatal intensive care (level 3) and needed more respiratory support than did those in the report group. The findings indicate that the availability of doppler studies leads to better obstetrical decision making. The purpose of this study was to evaluate the ability of two different modes of antepartum fetal testing to screen for the presence of peripartum morbidity, as measured by the cesarean delivery rate for fetal distress in labor.
                Over a 36-month period, all patients who were referred to the Fetal Assessment Unit at BC Women's Hospital because of a perceived increased fetal antepartum risk at a gestational age of > or =32 weeks of gestation were approached to participate in this study. Fetal surveillance of these women was allocated randomly to either umbilical artery Doppler ultrasound testing or nonstress testing as a screening test for fetal well-being. If either the umbilical artery Doppler testing or the nonstress testing was normal, patients were screened subsequently with the same technique, according to study protocol. When the Doppler study showed a systolic/diastolic ratio of >90th percentile or the nonstress testing was equivocal (ie, variable decelerations), an amniotic fluid index was performed, as an additional screening test. When the amniotic fluid index was abnormal (<5th percentile), induction and delivery were recommended. When the Doppler study showed absent or reversed diastolic blood flow or when the nonstress test result was abnormal, induction and delivery were recommended to the attending physician. Statistical comparisons between groups were performed with an unpaired t test for normally distributed continuous variables and chi(2) test for categoric variables.
                One thousand three hundred sixty patients were assigned randomly to groups in the study; 16 patients were lost to follow up. Six hundred forty-nine patients received Doppler testing and 691 received nonstress testing. The mean number of visits for the Doppler test and nonstress test groups was two versus two, respectively. The major indications for fetal assessment included postdates (43%), decreased fetal movement (22%), diabetes mellitus (11%), hypertension (10%), and intrauterine growth restriction (7%). The incidence of cesarean delivery for fetal distress was significantly lower in the Doppler group compared with the nonstress testing group (30 [4.6%] vs 60 [8.7%], respectively; P <.006). The greatest impact on the reduction in cesarean deliveries for fetal distress was seen in the subgroups in which the indication for testing was hypertension and suspected intrauterine growth restriction.
                Umbilical artery Doppler as a screening test for fetal well-being in a high-risk population was associated with a decreased incidence of cesarean delivery for fetal distress compared to the nonstress testing, with no increase in neonatal morbidity. A randomized clinical trial was performed to test the hypothesis that if suspected intrauterine growth retardation (IUGR) is associated with normal umbilical artery Doppler ultrasound findings, hospitalization can safely be avoided. One hundred and fifty women with singleton pregnancies and suspected IUGR were randomized between an intervention (n = 74) and a control group (n = 76). In the intervention group, clinicians were strongly requested not to hospitalize for suspected IUGR if the Doppler findings were normal. In the control group, the Doppler results were not revealed and the participants received the standard management for suspected IUGR. Endpoints of the trial were: costs in terms of hospitalization, perinatal outcome, neurological development, and postnatal growth. Duration of hospitalization was significantly shorter in the intervention group than in the control group. Contrary to expectations, the hospitalization rate during pregnancy in the intervention group was not below that of the control group. This negative finding was partly due to the admission of patients in the intervention group despite their normal Doppler results. Moreover, the trial might have induced a more critical attitude towards hospitalization in suspected IUGR, decreasing admission in the control group. No clear differences were found in perinatal outcome, neurological development, or postnatal growth. The results suggest that normal umbilical artery Doppler findings in suspected cases of IUGR justify outpatient management. To test whether the introduction of Doppler waveform analysis into the ultrasound department of a tertiary level hospital reduces neonatal morbidity and improves obstetric management.
                A randomized controlled trial.
                Department of Ultrasound, King Edward Memorial Hospital, Perth, Western Australia.
                505 women with pregnancy abnormalities referred to an ultrasound department for fetal investigation during the third trimester.
                Continuous wave Doppler studies of umbilical and uteroplacental arterial circulations. Results were revealed to patients and clinicians.
                Principal end point was the duration of neonatal stay in hospital; other end points included the number and type of fetal heart rate monitoring studies, obstetric interventions, frequency of fetal distress, birthweight, Apgar scores and need for neonatal intensive care.
                There was no effect on the duration of neonatal stay in hospital. Small trends in obstetric management were observed with study group patients having fewer contraction stress tests, less likelihood of antepartum fetal distress, and more likelihood of fetal distress after induction of labour leading to emergency caesarean section. Depressed Apgar scores were more frequent in the study group.
                Introduction of Doppler waveform studies did not result in reduced neonatal morbidity but did have a small effect on obstetric management. For each institution the role of Doppler studies in late pregnancy will be influenced by the usage of other tests of fetal welfare already entrenched in clinical practice.
Current evidence suggests that the use of Doppler ultrasound in high-risk pregnancies reduced the risk of perinatal deaths and resulted in less obstetric interventions. The quality of the current evidence was not of high quality, therefore, the results should be interpreted with some caution. Studies of high quality with follow-up studies on neurological development are needed.