Doppler assessment in Gynecological Ultrasound

The potential of Doppler ultrasound examination of the female pelvis has dramatically extended
since the advent of color Doppler, since it is now able to display anatomical features in B-mode
and blood flow in color at the same time. Practitioners have had access to ultrasound probes with
pulsed Doppler or color Doppler to illustrate the microcirculation for more than ten years.
Uterine vessels Doppler Assessment:
Using Doppler ultrasound, the main branch of the uterine artery is easily located at the
cervicocorporeal junction, with the help of real-time color imaging. Doppler velocimetry
measurements are usually performed near to this location, either transabdominally or
transvaginal. While absolute velocities have been of little or no clinical importance,
semiquantitative assessment of the velocity waveforms is commonly employed. Measurements
should be reported independently for the right and left uterine arteries, and the presence of
notching
should be noted.
Radiographic features
1. Ultrasound
The parameters used in the assessment of uteroplacental blood flow include:
 RI = resistive index
 PI = pulsatility index
 presence of persistent diastolic notching
2. Resistive index (RI)
This is calculated by the following equation:
RI = (PSV-EDV) / PSV = (peak systolic velocity - end-diastolic velocity) / peak systolic
velocity:
 normal (low resistance) RI <0.55
 high resistance
 bilateral notches RI >0.55
 unilateral notches RI >0.65
3. Pulsatility index (PI)
This is calculated by the following equation:
  PI = (PSV - EDV) / TAV = (peak systolic velocity - end-diastolic velocity) / time-
averaged velocity
Abnormal patterns include
 persistence of a high resistance flow throughout pregnancy
 persistence of notching throughout pregnancy
 reversal of diastolic flow throughout pregnancy: severe state
Uterine artery assessment in the first trimester
1. The transabdominal approach
The cervical canal is located after obtaining a midsagittal segment of the uterus
transabdominally. It is better if the mother's bladder is empty.The paracervical vascular
plexus is then visible after a lateral probe movement. The uterine artery is recognized when it
turns cranially to start its ascent to the uterine body when Color Doppler is activated. Before
the uterine artery splits into the arcuate arteries, measurements are obtained at this location.
The opposite side goes through the identical procedure.

Figure 1: Waveform from uterine artery obtained transabdominal

2. The transvaginal approach
The anterior fornix is where the probe is positioned transvaginal. The stages above are
carried out as the probe is pushed laterally to see the paracervical vascular plexus, much like
the transabdominal method.

Uterine artery assessment in the second trimester

1.The transabdominal approach
The probe is tilted transabdominal and positioned longitudinally in the lower lateral quadrant of
the abdomen medially. The uterine artery may be recognized by color flow mapping since it can
be seen crossing the external iliac artery. One centimeter is put downstream of this crossover
point for the sample volume. The sample volume should be applied to the artery right before the
uterine artery bifurcation in the rare percentage of situations when the uterine artery branches
before the junction with the external iliac artery. For the opposing uterine artery, the same
procedure is done. The uterus typically experiences dextrorotation as gestational age increases.
As a result, the left uterine artery runs less laterally than the right one.

Figure 2 Waveforms from uterine artery obtained transabdominally in second trimester.

Normal (a) and abnormal (b) waveforms; note notch (arrow) in Doppler signal in (b).
• Pathology
In a non-gravid state and at the very start of pregnancy the flow in the uterine artery is of high
pulsatility with a high systolic flow and low diastolic flow. A physiological early
diastolic notch may be present. Resistance to blood flow gradually drops during gestation as a
greater trophoblastic invasion of the myometrium takes place. An abnormally high resistance can
persist in pre-eclampsia and IUGR. If resistance is low, it has an excellent negative predictive
value with a <1% chance of developing either pre-eclampsia or having IUGR. A high resistance
often equates to a 70% chance of pre-eclampsia and 30% chance of IUGR. The early detection of
neoplasms and the assessment of the significance of undefined adnexal findings can be improved
considerably by evaluating organ perfusion, adding color-coded Doppler ultrasound to the purely
morphological descriptions of structural changes used previously. For instance, the differential
diagnosis of pelvic varices, which previously was difficult, can be facilitated considerably by the
use of color doppler.

Figure 2: Inconclusive cystic finding adjacent to the ovary

Figure 3: Display of vascular perfusion with pelvic varicosities.

Color Doppler in cervical cancer
It aid in the initial diagnosis of cervical cancer by providing information about blood flow within
the cervix and surrounding tissues. Areas of increased vascularity indicate the presence of a
tumor. The Doppler signals can help differentiate between benign and malignant lesions, as
cancerous growths often exhibit abnormal blood flow patterns. The stage of cervical cancer is
crucial for treatment planning. Color Doppler ultrasound also help in staging by evaluating the
extent of tumor invasion and detecting lymph node involvement. The presence of increased
blood flow in the tumor or in nearby lymph nodes can suggest a more advanced stage of the
disease. After initiating treatment for cervical cancer, monitoring the response to therapy is
essential. Color Doppler ultrasound can assess changes in blood flow within the tumor before
and after treatment.

Coronal scan demonstrate area of vascularity within the hypo echoic mass. No obvious
parametrical invasion is noted.

A mixed arterial and venous waveform is demonstrated through the region of

neovascularity in the mass
Ovarian masses
Doppler ultrasound can help differentiate between benign and malignant ovarian masses by
evaluating their blood flow patterns. Benign masses tend to exhibit normal or mildly increased
blood flow, while malignant masses often display chaotic and increased vascularity. Malignant
tumors may show irregular blood vessels and demonstrate a higher resistance index compared to
benign masses. The ultrasound feature of malignant ovarian masses are;
 Bilateral
 Large size.> 5cm
 Multiple lobules
 Papillary excrescence or solid areas
 Presence of ascities or metastasis
Color Doppler
Malignant growth are characterized by neoangiogenesis and blood vessels with a poorly
developed muscular is. The blood flow in these vessels is marked by low impedance and
correspondingly the RI <o.3 while benign ovarian masses and normal ovarian blood flow in
characterized by high RI
Resistance pattern in ovarian masses
 High resistance (RI <1>0.6)
Cyst adenoma, hemorrhagic cysts, dermoid tumor, endomitrioma
 Intermediate resistance (RI < 0.6 > 0.4)
Dermoid tumor, endomitrioma
 Low resistance (RI < 0.4 > 0)
Ovarian cancer, endomitrioma, corpus luteum, endomitrioma
 Endometrial cancer
In normal endometrium, atrophic endometrium and in most endometrial hyperplasia flow cannot
be detected. If flow is detected in endometrium and shows low resistance RI 0.42 it is most likely
endometrial cancer. Ultrasound marker of malignancy is;
 The disturbance of the interface between the endometrium and myometrium
 Presence of irregular, vascular mass lesion inside endometrial cavity
Color Doppler is useful as an adjacent in diagnosing endometrial cancer. The sub endometrial
blood flow and the blood flow in thickened and polypoidal endometrium shows low resistance
pattern in endometrial malignancy and the RI is <0.3
 Luteal cyst:
Luteal cyst is detected during the secretory phase of the menstrual cycle. Its size vary from 2-7
cm. the sonographic feature of luteal cyst are
 Heterogeneous content with fibrin septa
 Clot stimulating vegetation
 Pseudo- solid cysts
The color Doppler shows:
 Non vascular septa
 Vascularized thick wall
 May be misdiagnosed as a cyst
adenocarcinoma

Role of color Doppler in assessing endometrioma

Neovascularization detected in the wall of cyst. Absence of color flow in some echogenic portion
like blood clots in hemorrhagic cysts and endometrioma may suggest their benign cystic lesion
Neovascularization detected in the cyst wall. Absence of color flow Doppler in some
echogenic portion like blood clots in hemorrhagic cysts and endometrioma …suggest their
benign cystic nature
Doppler Finding Of Benign and Malignant Adnexal Masses
Benign ovarian tumor
 Regular distribution of blood vessels
 Blood vessels are equally calibrated
 Blood vessels have muscle fibers with moderate to high resistance index values
(RI=0.42)
Malignant ovarian tumor:
 Irregular distribution of blood vessels
 Blood vessels have irregular diameter
 Low resistance index values (RI=0.42)
 Display of tumoral lakes and and arterio-vanous shunts
This image shows an enlarged ovary >5cm with prominent peripheral nonovulatory
follicles. Small amount of free fluid.it may depict the cyst that predisposed the ovary to
torsion
Role in ectopic pregnancy
On color Doppler ring of fire is visualized owing to the low impedance high diastolic flow seen
in pregnancy that can surround the tubal ring of an ectopic pregnancy. However a hyper vascular
ring around the mass in the pelvis is more likely to be visualized around the corpus luteum than
an ectopic pregnancy. This is because both corpus luteum cyst and ectopic pregnancy can be
very vascular with low impedance flow. However, corpus luteum cysts are much more than
ectopic pregnancy.

Figure 4: Ectopic pregnancy with characteristic halo due to intense vascularization of the
chorion
 Umbilical Artery Doppler Assessment
Umbilical arterial (UA) Doppler assessment is used in the surveillance of fetal well-being in the
third trimester of pregnancy. Abnormal umbilical artery Doppler is a marker of placental
insufficiency and consequent intrauterine growth restriction (IUGR) or suspected pre-eclampsia.
Umbilical artery Doppler assessment has been shown to reduce perinatal mortality and morbidity
in high-risk obstetric situations. As a general rule, a degree of caution should be exercised with
the routine use of Doppler in pregnancy, due to the concerns related to heating/thermal effects
from the high intensities of Doppler ultrasound.
Indications:
In situations where there is a chance of fetal growth limitation or a poor perinatal outcome,
umbilical Doppler screening is advised. Twin-twin transfusion staging is another use for it. Low-
risk pregnancies do not require feto-placental circulation Doppler ultrasound examination.
Maternal circumstances:
 Type 2 diabetes
  Chronic renal disease
 States of prothrombotic hypertension
Pregnancy-related conditions:
 Suspected IUGR
 Previous pregnancy with IUGR or fetal death in utero
 Decreased fetal movement
 Oligohydramnios
 Polyhydramnios
 Multifetal pregnancy
Radiographic aspects:
Doppler ultrasonography:
The umbilical cord's spectral Doppler indices at the fetal, free loop, and placental ends are all
distinct, with the fetal end's impedance being the greatest. The fetal end is probably where the
alterations in the indices will be noticed earliest. The measures should ideally be taken in the free
cord, but for consistency in recording in instances that are being followed up, a fixed point, such
as the fetal end, placental end, or intra-abdominal section, would be preferable. Measurement in
a free loop is appropriate due to the challenge of measuring the chord at the fetal end in many
growth-restricted fetuses. In multiple pregnancy, assessment of umbilical artery blood flow can
be difficult, since there may be difficulty in assigning a cord loop to a specific fetus. It is better
to sample the umbilical artery just distal to the abdominal insertion of the umbilical cord.
However, the impedance there is higher than at the free loop and the placental cord insertion, so
appropriate reference charts are needed.
Figure 4: Umbilical artery waveforms obtained from same fetus, within 4 min of each
other, showing: (a) normal flow and (b) apparently very low diastolic flow and absent flow
signals at baseline, due to use of incorrect vessel wall filter (velocity reject is set too high).

Waveform:
The umbilical arterial waveform usually has a "saw tooth" pattern with flow always in the
forward direction that is towards the placenta. An abnormal waveform shows absent or reversed
diastolic flow. Before the 15th week, the absence of diastolic flow may be a normal finding.
The 95% confidence interval limit slowly decreases for both the resistive index (RI) and
pulsatility index (PI) through the course of gestation due to progressive maturation of the
placenta and an increase in the number of tertiary stem villi.

Figure 5: AFI is increased at 29.2 cm (i.e., there is polyhydramnios). Umbilical artery

Doppler is normal. Cervix measures 3.6 cm long and the internal os is closed.
Parameters:
The commonly used parameters are:
 umbilical arterial S/D ratio (SDR): systolic velocity / diastolic velocity
 pulsatility index (PI) (Gosling index): (PSV - EDV) / TAV
 resistive index (RI) (Pourcelot index): (PSV - EDV) / PSV
 PSV: peak systolic velocity
 EDV: end-diastolic velocity
 TAV: time-averaged velocity
 • Figure 6: The Umbilical Cord Shows: •Double nuchal cord: the placental end crossed over
the umbilical end(type A)
• Normal central insertion of placental end
• Normal 3-vessel configuration
• Normal Doppler study
The Doppler indices have been found to decline gradually with gestational age (i.e., there is more
diastolic flow as the fetus matures):
 S/D ratio mean value decreases with fetal age 8
 at 20 weeks, the 50th percentile for the S/D ratio is 4
 at 30 weeks, the 50th percentile is 2.83
 at 40 weeks, the 50th percentile is 2.18
 RI mean value decreases from 0.756 to 0.609
 PI mean value decreases from 1.270 to 0.967
Figure 7: The Umbilical artery -S/D, RI and PI and MCA - S/D, RI and PI are normal.
Fetal movement was observed.
Classification of severity:
In growth-restricted fetuses and fetuses developing intrauterine distress, the umbilical artery
blood velocity waveform usually changes in a progressive manner as below
 Reduction in end-diastolic flow: increasing RI values, PI values, and S/D ratio
 Absent end-diastolic flow (AEDF): RI = 1
 Reversal of end-diastolic flow (REDF)

Figure 8: Severe IUGR with an estimated fetal weight barely reaching 239g at 21WG
(usually approx. 500g is expected at this term). All biometric parameters < 3rd percentile.
Fetal middle cerebral artery Doppler assessment:
It is important to obtain and magnify an axial slice of the brain that includes the thalami and the
sphenoid bone wings. The circle of Willis and the proximal MCA should be identified using
color flow mapping. Next, as the internal carotid arteries systolic velocity declines with distance
from the point of origin of this conduit, the pulsed-wave Doppler gate should be positioned near
the proximal third of the MCA. As near to zero as feasible should be the angle between the
ultrasonic beam and the direction of blood flow. The fetal head should not be subjected to any
undue pressure. A minimum of three and a maximum of ten successive waveforms should be
written down. The PSV (cm/s) is taken to be the peak of the waveform. The PSV can be
determined manually or using an auto trace. The latter produces medians that are much lower
than the former but that are closer to reported medians used in clinical practice11. Normally,
auto trace measurement is used to determine PI, although manual tracing is also acceptable.
Figure 9: Middle cerebral artery Doppler remained normal, indicating a relative
vasodilation to preserve brain from damage: vascular redistribution, with a cerebra-
placental ratio < 1, RI MCA / RI umbilical <1.

Figure 10: Color Flow mapping of the circle of Willis

Ductus Venosus Doppler Assessment
The ductus venosus (DV) connects the intra-abdominal portion of the umbilical vein to the left
portion of the inferior vena cava just below the diaphragm. The vessel is identified by visualizing
this connection by 2D imaging either in a midsagittal longitudinal plane of the fetal trunk or in
an oblique transverse plane through the upper abdomen. Color flow mapping demonstrating the
high velocity at the narrow entrance of the DV confirms its identification and indicates the
standard sampling site for Doppler measurements. Doppler measurement is best achieved in the
sagittal plane from the anterior lower fetal abdomen since alignment with the isthmus can be
well controlled. Sagittal insonation through the chest is also a good option but more demanding.
An oblique section provides reasonable access for an anterior or posterior insonation, yielding
robust waveforms but with less control of angle and absolute velocities. In early pregnancy and
in compromised pregnancies particular care has to be taken to reduce the sample volume
appropriately in order to ensure clean recording of the lowest velocity during atrial contraction.
The waveform is usually triphasic, but biphasic and non-pulsating recordings, though rarer, may
be seen in healthy fetuses. The velocities are relatively high, between 55 and 90 cm/s for most of
the second half of pregnancy, but lower in early pregnancy.

Figure 11: Ductus venosus Doppler: A wave is flat, which reflects increased filling pressure
in the right atrium.

Umbilical venous flow Doppler assessment

Umbilical venous flow in the physiological situation comprises a monophasic non-pulsatile flow
pattern in the umbilical vein with a mean velocity of 10-15 cm/s. Since a normal umbilical vein
supplies a continuous forward flow of oxygenated blood to the fetal heart, the presence of
pulsatility implies a pathological state unless in the following situations:
 Early in pregnancy: up to ~13 weeks gestation
The presence of pulsatility may be higher in chromosomally abnormal fetuses even in early
pregnancy:
 When confounded by other movement variables such as
1. Fetal breathing movement
2. Fetal hiccups
Pulsations of the umbilical venous system, especially double pulsations have been associated
with increase in the perinatal mortality when associated with the absent and reversed end-
diastolic flow velocity in the umbilical artery.

Figure 12: Severe symmetric growth restriction. EFW on 2nd centile. BPD, HC and AC <
2nd centile.
UA DOPPLER:
 Absent end-diastolic flow
 MCA PI:1.29(<5TH Centile)
 DV: absent to reverse a wave
 UV: pulsatile
 AFI: 11(normal)

Figure 13: Ductus venosus Doppler recording with sagittal insonation without aligning with
the isthmic portion without angle correction.