Advances in Clinical and Experimental Medicine

Title abbreviation: Adv Clin Exp Med
JCR Impact Factor (IF) – 2.1 (5-Year IF – 2.0)
Journal Citation Indicator (JCI) (2023) – 0.4
Scopus CiteScore – 3.7 (CiteScore Tracker – 4.0)
Index Copernicus  – 171.00; MNiSW – 70 pts

ISSN 1899–5276 (print)
ISSN 2451-2680 (online)
Periodicity – monthly

Download original text (EN)

Advances in Clinical and Experimental Medicine

2009, vol. 18, nr 5, September-October, p. 481–486

Publication type: original article

Language: English

Doppler Parameters Predicting Fetal Heart Rate Abnormalities in Diabetic Pregnancies

Parametry badania dopplerowskiego pozwalające przewidywać zaburzenia w akcji serca płodu u ciężarnych chorych na cukrzycę

Małgorzata Pawelec1,, Andrzej Karmowski1,, Joanna Krzemieniewska1,, Marek Kaniak1,, Mikołaj Karmowski1,

1 First Clinic of Gynecology and Obstetrics, Wroclaw Medical University, Poland

Abstract

Background. Uteroplacental insufficiency is reflected by an increased pulsatility index in the umbilical artery (Umb PI). This leads to a redistribution of blood in the fetus (brain sparing), which is reflected by an increased middle cerebral artery PI (MCA PI) to Umb PI ratio (AI – acidemic index) and may cause a reduction in blood flow. An abnormally low AI is connected with unfavorable pregnancy outcome.
Objectives. The primary purpose of this study was to determine diabetes mellitus and circulatory variables that could relate to low arterial pH in the umbilical cord measured immediately after birth.
Material and Methods. The study group comprised 64 diabetic women with class B, C, D, or F diabetes and at least 26 weeks pregnant. Umb PI and MCA PI were measured every two days from admission to delivery. Doppler MCA PI, Umb PI, and AI were compared with fetal heart traces (NST) and pH from the umbilical artery measured immediately after birth.
Results. During the study about 34% of the fetuses of the diabetic mothers showed flow redistribution and nearly 22% abnormal NSTs. Abnormal AI was associated with abnormal NST in nearly 19% of cases. Doppler velocimetry is in itself good in confirming acidosis, detecting 90% of all acidemias (pH < 7.1). Abnormal Doppler velocimetry predicted fetal heart rate abnormalities in patients with B, C, D, or F diabetes about 8 days before they occurred.
Conclusion. No cardiotocographic parameter alone was found to be a good predictor of umbilical acidemia. An abnormal NST in diabetic pregnancies should be verified by the AI. Both methods are noninvasive and safe. Abnormal cardiotocographic changes were usually preceded by abnormal MCA PI, Umb PI, and AI which occurred on average about 8 days earlier. Using both methods together, a predictive and a predisposal value of umbilical acidemia of 91.7 and 95% were obtained.

Streszczenie

Wprowadzenie. Około 40% noworodków rodzących się w naszej klinice z ciąż matek chorych na cukrzycę klasy B, C, D, F według klasyfikacji White, ma bezpośrednio po porodzie kwasicę (pH < 7,1).
Cel pracy. Celem pracy było zidentyfikowanie wskaźników świadczących o zagrożeniu kwasicą płodów matek chorych na cukrzycę B–D oraz F wg White.
Materiał i metody. Wykonując u ciężarnych chorych na cukrzycę B–F wg klasyfikacji White badania KTG oraz USG w ciągu ponad 2 lat, autorzy stwierdzili, że u ok. 34% płodów wystąpiły w badaniu dopplerowskim cechy redystrybucji, na podstawie pomiarów PI (pulsatility index) w tętnicy pępowinowej i tętnicy środkowej mózgu.
Wyniki. U około 22% ciężarnych wystąpiły patologiczne zapisy kardiotograficzne. Nieprawidłowy wskaźnik kwasicy (acidemic index), będący stosunkiem MCA PI do Umb PI (z punktem odcięcia 1.1) towarzyszył patologicznym zapisom KTG w ok. 19%. Indeks kwasicy (acidemic index) pozwala dobrze zidentyfikować te noworodki, które nie będą miały kwasicy (pH < 7,1) bezpośrednio po porodzie (95,2%). Około 81% noworodków z nieprawidłowymi wynikami badań dopplerowskich, opisanych w pracy, będzie miało kwasicę (pH < 7,1), jeśli obydwa wskaźniki, tj. KTG i AI, będą nieprawidłowe, to dla kwasicy PPV wynosi 91,7%, a NPV 95%.
Wnioski. Badanie dopplerowskie jest samo w sobie dobrym wskaźnikiem kwasicy. Pozwala na wychwycenie 90% wszystkich kwasic wykrytych w krwi pępowinowej bezpośrednio po porodzie. Nieprawidłowe wartości wskaźników badania dopplerowskiego wyprzedzały średnio o 8 dni patologiczne zmiany w KTG. Oba sposoby przewidywania kwasicy po porodzie są metodami bezpiecznymi i nieinwazyjnymi i pozwalają zrezygnować z konieczności stosowania kordocentezy oraz pozwalają zmniejszyć liczbę cięć cesarskich wykonywanych z powodu nieprawidłowych zapisów KTG u ciężarnych chorych na cukrzycę.

Key words

NST (non−stress test), CTG (cardiotocography), PI (pulsatility index), BCDF diabetes mellitus, AI (acidemic index), FHR (fetal heart rate)

Słowa kluczowe

test niestresowy, kardiotokografia, cukrzyca ciężarnych klasy B, C, D, F, wskaźnik kwasicy, akcja serca płodu

References (40)

  1. White P: Pregnancy complicating diabetes. Am J Med 1949, 7 (5), 609–616.
  2. Pawelec M, Karmowski A, Wiklińska K, Karmowski M, Pietras J: An Analysis of the ST Segment, QRS Complex, and R−R Intervals of Transabdominal Fetal Electrocardiograms in Diabetic Pregnancies. Adv Clin Exp Med 2008, 17, 6, 643–647.
  3. Creasy RK: Treatment of Diabetes in Pregnancy. Postgraduate Course in Management of High Risk Pregnancy. Kraków 1984, 51–56.
  4. Dunne F, Brydon P, Smith K, Gee H: Pregnancy in women with Type 2 diabetes: 12 years outcome data 1990–2002. Diabet Med 2003, 20 (9), 734–738.
  5. Al−Dabbous IA, Owa JA, Nasserallah ZA, al−Qurash IS: Perinatal morbidity and mortality in offspring of diabetic mothers in Qatif, Saudi Arabia. Eur J Obstet Gynecol Reprod Biol. 1996, 65 (2), 165–169.
  6. Gabbe SG, Lowensohn RI, Wu PY, Guerra G: Current patterns of neonatal morbidity and mortality in infants of diabetic mothers. The Diabetes Educator 1, 1993 19, 15–17.
  7. Casson IF, Clarke CA, Howard CV, McKendrick O, Pennycook S, Pharoah POD, Platt MJ, Stanisstreet M, van Velszen D, Walkinshaw S: Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population cohort study. BMJ 1997, 315, 275–278.
  8. Dunne F: Type 2 diabetes and pregnancy. Semin Fetal Neonatal Med 2005, 10 (4), 333–339.
  9. Ostlund E, Hanson U: Antenatal nonstress test in complicated and uncomplicated pregnancies in type−1−diabetic women. Eur J Obstet Gynecol Reprod Biol 1991, 21, 39 (1), 13–18.
  10. Watson D, Rowan J, Neale L, Battin MR: Admissions to neonatal intensive care unit following pregnancies complicated by gestational or type 2 diabetes. Aust N Z J Obstet Gynaecol 2003, 43 (6), 429–432.
  11. Zhu L, Nakabayshi M, Takeda Y: Statistical analysis of perinatal outcomes in pregnancy complicated with diabetes mellitus. J Obstet Gynaecol Res 1997, 23 (6), 555–563.
  12. Landon MB, Gabbe SG, Bruner JP, Ludmir J: Doppler umbilical artery velocimetry in pregnancy complicated by insulin−dependent diabetes mellitus. Obstet Gynecol 1989, 73 (6), 961–965.
  13. Dicker D, Goldman JA, Yeshaya A, Peleg D: Umbilical artery velocimetry in insulin dependent diabetes mellitus (IDDM) pregnancies. J Perinat Med 1990, 18 (5), 391–395.
  14. Simanaviciute D, Gudmundsson S: Fetal middle cerebral to uterine artery pulsatility index ratios in normal and pre−eclamptic pregnancies. Ultrasound Obstet Gynecol 2006, 28 (6), 794–801.
  15. Harrington K, Carptenter RG, Nguyen M, Campbell S: Changes observed in Doppler studies of the fetal circulation in pregnancies complicated by pre−eclampsia or the delivery of a small−for−gestational−age baby. I. Cross−sectional analysis. Ultrasound Obstet Gynecol 1995, 6 (1), 19–28.
  16. Nicolaides KH, Rizzo G, Hecher K: Placental and fetal Doppler. Diploma in Fetal Medicine Series. The Parthenon Publishing Group. New York–London 2000.
  17. Little JW: Recent advances in diabetes mellitus of interest to dentistry. Spec Care Dentist 2000, 20 (2), 46–52.
  18. Bradley RJ, Brudenell JM, Nicolaides KH: Fetal acidosis and hyperlacticaemia diagnosed by cordocentesis in pregnancies complicated by maternal diabetes mellitus. Diabet Med 1991, 8, 464–468.
  19. Salvesen DR, Brudenell JM, Nicolaides KH: Fetal polycythemia and thrombocytopenia in pregnancies complicated by maternal diabetes mellitus. Am J Obstet Gynecol 1992, 166, 1287–1292.
  20. Salvesen DR, Brudenell JM, Nicolaides KH: Fetal plasma erythropoietin in pregnancies complicated by maternal diabetes mellitus. Am J Obstet Gynecol 1993, 168, 88–94.
  21. Sotero de Menezes M, Shaw DWW: Hypoxic−Ischemic Brain Injury in the Newborn. emedicine.medscape.com/ /article/1183351 updated Apr 4 2006. [accessed 2009.06.14]
  22. Eisner DA, Diaz M, Li Y, O’Nill S, Trafford AW: Stability and instability of regulation of intracellular calcium. Exp Physiol 2005, 90 (1), 3–12.
  23. Raha S, Robinson BH: Mitochondria, oxygen free radicals, and apoptosis. Am J Med Genet 2001, 106, 62–70.
  24. Buisson A, Plotkine M, Boulu RG: The neuroprotective effect of a nitric oxide inhibitor in a rat model of focal cerebral ischaemia. Br J Pharmacol, 1992, 106 (4), 766–767.
  25. Wright P: Nitric oxide: from menace to marvel of the decade. Association of British Science Writers. 1996 May. www.absw.org.uk/Briefings?Nitric%20oxide.htm [accessed 2009.06.14]
  26. Compagnoni G, Bottura Ch, Cavallaro G, Cristofori G, Lista G, Mosca F: Safety of deep hypothermia in treating neonatal asphyxia. Neonatology 2008, 93, 230–235.
  27. Sikora E, Bielak−Zmijewska A, Magalska A, Piwocka K, Mosieniak G, Kalinowska M, Widlak P, Cymerman IA, Bujnicki JM: Curcumin induces caspase−3−dependent apoptotic pathway but inhibits DNA fragmentation factor 40/caspase−activated DNase endonuclease in human Jurkat Cells. Mol Cancer Ther 2006, 5 (4), 927–934.
  28. Landon MB, Langer O, Gabbe SG, Schick C, Brustman L: Fetal surveillance in pregnancies complicated by insulin−dependent diabetes mellitus. Am J Obstet Gynecol 1992, 167 (3), 617–621.
  29. Nicolaides KH, Salvessen DR, Higueras MT, Mansur CA, Freeman J, Brudenell JM: Placental and fetal Doppler velocimetry in pregnancies complicated by maternal diabetes mellitus. Am J Obstet Gynecol 1993, 168 (2), 695–699.
  30. Salvessen DR, Higueras MT, Mansur CA, Freeman J, Brudenell JM, Nicolaides KH: Placental and fetal Doppler velocimetry in pregnancies complicated by maternal diabetes mellitus. Am J Obstet Gynecol 1993, 168 (2), 645–652.
  31. Casanova MS, Mauad−Filho F, Perreira AC, Mauad FM, Freitas RAO: Correlation between the antepartum cardiotocographic of the Doppler effect in fetuses considered clinically normal. J Perinat Med 2001, 29, Suppl 1, 84–85.
  32. Kjos SL, Leung A, Henry OA, Victor MR, Paul RH, Medearis AL: Antepartum surveillance in diabetic pregnancies: predictors of fetal distress in labor. Am J Obstet Gynecol 1995, 173 (5), 1532–1539.
  33. Ortellado M, Aparicio de Real C, Mendoza L, Acotsa A: Nonstress test and perinatal outcome in the national maternity from Asuncion, Paraguay. J Perinat Med 2001, 29, Suppl 1, 119.
  34. Yoon BH, Romero R, Roh CR, Kim SH, Ager JW, Syn HC, Cotton D, Kim SW: Relationship between the fetal biophysical profile score, umbilical artery Doppler velocimetry, and fetal blood acid−base status determined by cordocentesis. M J Obstet Gynecol 1993, 169 (6), 1586–1594.
  35. Harman CR, Baschat AA: Comprehensive assessment of fetal well−being: which Doppler tests should be performed? Curr Opin Obstet Gynecol 2003, 15 (2), 147–157.
  36. Yoshimura S, Masuzaki H, Miura K, Gotoh H, Ishimaru T: Fetal blood flow redistribution in term intrauterine growth retardation (IUGR) and post−natal growth. Int J Gynaecol Obstet 1998, 60 (1), 3–8.
  37. Johnstone FD, Steel JE, Haddad NG, Hoskins PR, Greer IA, Chambers S: Doppler umbilical artery flow velocity waveforms in diabetic pregnancy. Br J Obstet Gynaecol 1992, 99, 135–140.
  38. Iwasaki T: The standard curves of pulsatility index from uterine and fetal blood flow, and their efficacy in clinical management of intrauterine growth retardation. A comparison with fetal blood gas analysis. Nippon Ika Daigaku Zasshi 1996, 63 (5), 327–342.
  39. Turan S, Turan OM, Berg C, Moyano D, Bhide A, Bower S, Thilaganathan B, Gembruch U, Nicolaides K, Harman C, Baschad AA: Computerized fetal heart rate analysis, Doppler ultrasound and biophysical profile score in the prediction of acid−base status of growth−restricted fetuses. Ultrasound Obstet Gynecol 2007, 30 (5), 750–756.
  40. Kim WJ, Kim SW: Relationship between umbilical artery pulsatility index of Doppler velocimetry and umbilical venous blood gases measured by cordocentesis. Seoul J Med 1995, 36 (1), 35–42.
© Wroclaw Medical University