Uterine artery doppler – when would you order one?

13th February 2024, NIA Diagnostic Imaging

Uterine Artery

Commonly, uterine artery doppler ultrasound is conducted to measure the blood flow in the uterine arteries. This specific ultrasound allows for qualitative information to be gathered on the presence/absence of flow, the direction of flow, the quality of flow, to determine if the flow is laminar or turbulent and to distinguish waveform shape (low resistance, high resistance, early diastolic notch) (Naguib et al.,2012).

The uterine arteries are the vessels that provide blood flow to the uterus, which then supplies the placenta. There are two uterine arteries, one on the left and one on the right side of the uterus, arising from the anterior deviate of the internal iliac artery. As such, a fetus will be able to grow healthily if there is sufficient blood flow through these arteries as the placenta will develop normally (Chaudry et al.,2023).
In cases with defective trophoblast invasion, impaired placentation may occur which may result in pre-eclampsia and early onset fetal growth restriction (Chaudry et al., 2023).

At NIA Diagnostic Imaging, our highly skilled sonographers frequently perform uterine artery doppler assessment during obstetric ultrasounds, as we value the importance of assessing placental flow. Ultrasound is a highly advantageous imaging modality as it is non-invasive in nature and utilises non-ionising radiation, hence being extremely safe and beneficial for patients (Naguib et al.,2012).
At NIA Diagnostic Imaging, we utilise the latest GE LOGIQ E10 series ultrasound system to perform uterine artery doppler assessment. Assessment involves scanning both the left and right uterine arteries and reporting their PI (Pulsatility Index).
Indications of uterine artery doppler include:
• Previous history of pre-eclampsia
• Previous history of child with IUGR
• Unexplained high maternal serum AFP level
• Unexplained high HCG levels (Barati M et al., 2014).

The onset of high blood pressure after 20 weeks of pregnancy, is strongly indicative of pre-eclampsia, which severely increases the potential of adverse outcomes for both the mother and the fetus. Hence, uterine artery doppler evaluation is essential to identify pregnancies that may be at increased risk of the development of pre-eclampsia, as it often leads to severe growth restriction and small fetus for gestational age. In pregnancies complicated by intrauterine growth restriction and pre-eclampsia, the impedance to flow in the uterine arteries is increased. In these scenarios, there is an increased likelihood of:

• Shorter duration of pregnancy
• Emergency caesarean delivery
• Placental abruption
• Poorer neonatal outcome

(Nicolaides et al., 2002)

REFERENCES

Barati M, Shahbazian N, Ahmadi L, Masihi S. Diagnostic evaluation of uterine artery Doppler sonography for the prediction of adverse pregnancy outcomes. J Res Med Sci. 2014 Jun;19(6):515-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155705/#:~:text=Abnormal%20uterine%20artery%20Doppler%20result,for%20identifying%20high%2Drisk%20pregnancies.
Chaudhry, R. and Chaudhry, K. (2023) Anatomy, Abdomen and Pelvis: Uterine Arteries. https://www.ncbi.nlm.nih.gov/books/NBK482267/ Isuog (2022) Uterine arteries Doppler ultrasound, International Society of Ultrasound in Obstetrics & Gynecology. Available at: https://www.isuog.org/clinical-resources/patient-information-series/patient-information-pregnancy-conditions/growth-and-fluid/uterine-arteries-doppler-ultrasound.html (Accessed: 09 February 2024).
Naguib, N.N. et al. (2012) ‘Role of uterine artery Doppler in the management of uterine leiomyoma by arterial embolization’, Ultrasound in Obstetrics & Gynecology, 40(4), pp. 452–458. doi:10.1002/uog.11074. Nicolaides, K. et al. (2002) Doppler in Obstetrics, International Society of Ultrasound in Obstetrics & Gynecology. Available at: https://www.isuog.org/clinical-resources/patient-information-series/patient-information-pregnancy-conditions/growth-and-fluid/uterine-arteries-doppler-ultrasound.html (Accessed: 09 February 2024).

PFO Closure

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–

A multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.

Results:

Primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P = 0.37)

Conclusion:

“In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure

with a device did not offer a greater benefit than medical therapy alone for the

prevention of recurrent stroke or TIA”

2 Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377: 1022–

A multicenter, randomised, open-label trial ,randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomisation.

Results:

Recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient years, respectively (hazard ratio 0.55; 0.31 – 0.999; P = 0.046)

Conclusion:

“Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up.”

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–

A prospective, multicenter, randomised, event-driven trial, randomly assigned patients to medical therapy alone (anti-platelet or warfarin therapy) or closure of the patent foramen ovale.

Results:

9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 0.22 – 1.11; P = 0.08). The primary analysis of the intentionto- treat cohort showed a nominal 51% hazard rate reduction with closure, but the reduction did not reach significance.

Conclusions:

” …there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischaemic stroke.”

Sondergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377: 1033–

Multinational trial involving patients with a PFO who had had a cryptogenic stroke, randomly assigned patients to undergo PFO closure plus antiplatelet therapy or to receive antiplatelet therapy alone.

Results:

During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 0.09 to 0.62; P=0.002).

Conclusions:

“Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.”

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377: 1011–

In a multicenter, randomised, open-label trial patients 16-60 years of age who had had a recent stroke attributed to PFO, to transcatheter PFO closure plus long-term antiplatelet therapy, antiplatelet therapy alone or oral anticoagulation.

Results:

No stroke occurred among patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet- only group (hazard ratio, 0.03; 0 to 0.26; P<0.001). Large number of patients discontinued anti-coagulation in the anti-coagulant group and statistical significance was not analysed because the study was not adequately powered to compare outcomes.

Conclusion:

“Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.”

Lee PH, Song J-K, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO Trial. J Am Coll Cardiol 2018; 71: 2335–

Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group.

Results:

No events occurred in the PFO closure group. 12.9% of patients in the medication group had an event (p= 0.023).

Conclusion:

“PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence”