Re: Hi
From: James S Smeltzer MD (gaperina@mindspring.com)
Thu Jan 31 22:13:38 2002
Sure, You are correct that it is the simple differencve and has been well
validated to be very stable from 28 to 42 weeks. Fifth %ile is about .07,
10%ile is .11. Median is .24, and all these numbers are stable above 28
weeks to post dates. Many diabetics will not show much in the umbilical
until you compare it to the cerebral.
Below 10%ile retest early - three to four weeks or if status change and
watch for iugr or FHR or BPP changes or PIH. Below 5%ile needs weekly
testing with NST, daily kick counts and weekly reassessment. If negative
consider biweekly testing or hospitalization and AEDV or REDV hospitalize,
NST at least daily, and deliver if forseeable benefit greater than
forseeable risk of early delivery.
Using this algorithm we have not lost a baby in utero, tho some severe
preterm and SGA babies have died of NEC, sepsis or severe immaturity. I do
not ever deliver for doppler alone prior to 36 weeks. A lot of these will
end up showing PIH in labor or postpartum. We had two in the unit last
week with postpartum HELLP, only minimal sighs of PIH antepartum but
abnormal dopplers, one with SGA and the other not.
The French version of this is the CUR (Dr. Philippe Arbeille) or cerebral
umbilical ratio, using resistance index ratios. (Some use PI, favored by
Gramellini & the Italians, who have done a lot of this work). The abnormal
is under 1.1, with those under 1 in more trouble. I don't use it because
it requires long division, which I cannot do well in my head, and was not
completely independent of gestational age in my series of 100% normal
outcome patients. The idea was theirs and the right one IMHO. Theirs has
been used in over 100 studies, you may want to check out below. The DRI
has the advantages I mentioned for me since I am simple-minded, impatient,
and lazy, and it is mine. For studies, it has an additional advantage of
homogeneity of variance and appropriate application of parametric
statistics that you just can't get from a ratio. The information is
essentially the same, however.
The relationship uses the fact that both indices change normally with
gestation and vary together among normal fetuses, and should be related in
normal circumstances in the normal fetus. Adaptive change is to increase
blood flow to the brain first - before visible effect in the umbilical
circulation. Failure of adaptive reserve is increasing brain perfusion at
the expense of placental. The is the exquisite beauty of the evaluation
system. Also the tremendous reassurance a normal relationship gives. You
can truly identify those babies who are NOT in or near trouble and need
less attention. Since I take care of many cash-paying poor people who have
to pay $50 for an NST this helps a lot.
There is some promising work regarding the IVC doppler - proposed by Dr.
Kathy Reed originally, and now the ductus venosus, that is based on the
fact that severe hypoxia and acidosis produce diastolic compliance problems
in the failing heart and poor ejection fraction. I use this in severely
preterm fetuses frequently to identify those who are likely to benefit from
delivery. These both lead to more retrograde flow during the atrial
contraction. Some of these references, including comparisons, are below.
Hope this helps.
;^)
Jim Smeltzer
PS
1. Smeltzer J, Lieberman S, Kivikoski A, Shyken J: Middle cerebral and
umbilical doppler norms based on sonographic fetal measurements during the
third trimester. J Mat Fet Med 1993;2:15-20.
vs
"cerebral umbilical ratio" Searched on NLM Gateway (which has abstracts for
almost all of these)
http://gateway.nlm.nih.gov/gw/Cmd
- NB there are CUR and CPR out there, using RI and PI. Most use MCA but
some early work - such as Wladamiroff with the ICA or CCA and PI. These
are essentially the SAME - and the same as my DRI (Dynamic reserve index
;^) except the normal ranges - in practice)
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