Clinical significance of early diastolic notch depth: uterine artery Doppler velocimetry in the third trimester

Bridging the notch: quantification of the end diastolic notch to better predict fetal growth restriction

PURPOSE

We aimed to evaluate several quantitative methods to describe the diastolic notch (DN) and compare their performance in the prediction of fetal growth restriction.

MATERIALS AND METHODS

Patients who underwent a placental scan at 16-26 weeks of gestation and delivered between Jan 2016 and Dec 2020 were included. The uterine artery pulsatility index was measured for all of the patients. In patients with a DN, it was quantified using the notch index and notch depth index. Odds ratios for small for gestational age neonates (defined as birth weight <10th and <5th percentile) were calculated. Predictive values of uterine artery pulsatility, notch, and notch depth index for fetal growth restriction were calculated.

RESULTS

Overall, 514 patients were included, with 69 (13.4%) of them delivering a small for gestational age neonate (birth weight<10th percentile). Of these, 20 (20.9%) had a mean uterine artery pulsatility index >95th percentile, 13 (18.8%) had a unilateral notch, and 11 (15.9%) had a bilateral notch. 16 patients (23.2%) had both a high uterine artery pulsatility index (>95th percentile) and a diastolic notch. Comparison of the performance between uterine artery pulsatility, notch, and notch depth index using receiver operating characteristic curves to predict fetal growth restriction <10th percentile found area under the curve values of 0.659, 0.679, and 0.704, respectively, with overlapping confidence intervals.

CONCLUSION

Quantifying the diastolic notch at 16-26 weeks of gestation did not provide any added benefit in terms of prediction of neonatal birth weight below the 10th or 5th percentile for gestational age, compared with uterine artery pulsatility index.

Ultrasonographic assessment of abnormal fetal growth related to uteroplacental-fetal biometrics and Doppler (U-AID) indices: Protocol for multicenter retrospective cohort study trial

Fetal growth restriction (FGR) is one of the leading causes of perinatal morbidity and mortality. Many studies have reported an association between FGR and fetal Doppler indices focusing on umbilical artery (UA), middle cerebral artery (MCA), and ductus venosus (DV). The uteroplacental-fetal circulation which affects the fetal growth consists of not only UA, MCA, and DV, but also umbilical vein (UV), placenta and uterus itself. Nevertheless, there is a paucity of large-scale cohort studies that have assessed the association between UV, uterine wall, and placental thickness with perinatal outcomes in FGR, in conjunction with all components of the uteroplacental-fetal circulation. Therefore, this multicenter study will evaluate the association among UV absolute flow, placental thickness, and uterine wall thickness and adverse perinatal outcome in FGR fetuses. This multicenter retrospective cohort study will include singleton pregnant women who undergo at least one routine fetal ultrasound scan during routine antepartum care. Pregnant women with fetuses having structural or chromosomal abnormalities will be excluded. The U-AID indices (UtA, UA, MCA, and UV flow, placental and uterine wall thickness, and estimated fetal body weight) will be measured during each trimester of pregnancy. The study population will be divided into two groups: (1) FGR group (pregnant women with FGR fetuses) and (2) control group (those with normal growth fetus). We will assess the association between U-AID indices and adverse perinatal outcomes in the FGR group and the difference in U-AID indices between the two groups.

Feasibility of Vascular Parameter Estimation for Assessing Hypertensive Pregnancy Disorders

Hypertensive pregnancy disorders (HPDs), such as pre-eclampsia, are leading sources of both maternal and fetal morbidity in pregnancy. Noninvasive imaging, such as ultrasound (US) and magnetic resonance imaging (MRI), is an important tool for predicting and monitoring these high risk pregnancies. While imaging can measure hemodynamic parameters, such as uterine artery pulsatility and resistivity indices (PI and RI), the interpretation of such metrics for disease assessment relies on ad hoc standards, which provide limited insight to the physical mechanisms underlying the emergence of hypertensive pregnancy disorders. To provide meaningful interpretation of measured hemodynamic data in patients, advances in computational fluid dynamics can be brought to bear. In this work, we develop a patient-specific computational framework that combines Bayesian inference with a reduced-order fluid dynamics model to infer parameters, such as vascular resistance, compliance, and vessel cross-sectional area, known to be related to the development of hypertension. The proposed framework enables the prediction of hemodynamic quantities of interest, such as pressure and velocity, directly from sparse and noisy MRI measurements. We illustrate the effectiveness of this approach in two systemic arterial network geometries: an aorta with branching carotid artery and a maternal pelvic arterial network. For both cases, the model can reconstruct the provided measurements and infer parameters of interest. In the case of the maternal pelvic arteries, the model can make a distinction between the pregnancies destined to develop hypertension and those that remain normotensive, expressed through the value range of the predicted absolute pressure.

Loss of E-Cadherin Staining Continuity in the Trophoblastic Basal Membrane Correlates with Increased Resistance in Uterine Arteries and Proteinuria in Patients with Pregnancy-Induced Hypertension

Pregnancy-induced hypertension (PIH), especially when complicated with pre-eclampsia (PE), could be a life-threatening complication of pregnancy. Pre-eclampsia is one of the leading causes of perinatal morbidity and mortality in women. Pre-eclampsia is mainly characterized by hypertension and kidney damage with proteinuria. Abnormal placentation and altered structure of the placental barrier are believed to participate in the pathogenesis of pregnancy-induced hypertension, leading to PE. In the current study, we aimed to analyze the immunohistochemical expression pattern of E-cadherin and p120, two markers of epithelial–mesenchymal transition, in placental samples derived from a group of 55 patients with pregnancy-induced hypertension, including pre-eclampsia and 37 healthy pregnant controls. The results were correlated with the presence of an obtained early uterine artery flow notching during diastole on Doppler ultrasound. We observed a higher frequency of discontinuous E-cadherin staining in the basement membrane of syncytiotrophoblast in patients with PIH/PE compared to controls (p < 0.001, Fisher’s exact test). Moreover, the loss of continuity of E-cadherin expression correlated with the presence of a bilateral early diastolic notch on Doppler ultrasound (p < 0.001, Fisher’s exact test) and the presence of proteinuria (p = 0.013, Fisher’s exact test). These findings suggest that E-cadherin contributes to the integrity of the placental barrier, and its loss could be an immunohistochemical marker of PE.

Role of Doppler Waveforms in Pregnancy-Induced Hypertension and Its Correlation With Perinatal Outcome

Objectives

The present study aims to measure the role of Doppler waveforms in pregnancy-induced hypertension (PIH) and its relationship with the perinatal outcome.

Methods

We have studied 50 pregnant women with PIH with gestational age (GA) 30-40 weeks for Umbilical Artery (UmA), Middle Cerebral Artery (MCA) and Uterine Artery (UtA) Doppler waveforms. Comparison between the various Doppler indices, i.e., Pulsatility Index (PI), Resistive Index (RI) and S/D ratio, with the severity of the disease and the perinatal outcomes were evaluated using appropriate statistical tests considering a threshold value of p-value <0.05 as significant. The Statistical Package for the Social Sciences (SPSS) version-16 (SPSS Inc, Chicago, USA) and MedCalc software (MedCalc Software Ltd, Ostend, Belgium) were used for data analysis.

Results

Half (50%) of the cases attributed to the 26 to 30 years age group were at 38 to 40 weeks of gestation. Out of the 50 patients, 68% were primigravida, and 74% had severe PIH. Mean UmA PI, mean MCA PI, mean MCA RI, and mean Cerebro Placental Ratio (CPR) were differed significantly among mild and severe PIH patients (p-value<0.05). Perinatal outcomes in 33 (66%) cases were adverse. The abnormal UmA RI, MCA RI, MCA PI, MCA S/D were significantly linked with poor pregnancy outcomes (p-value <0.05). PIH cases with the presence of early diastolic notch of UtA (p-value <0.01), abnormal PI CPR (p-value <0.001) and S/D CPR (p-value <0.003) were observed to have more adverse outcomes. PI CPR had the highest sensitivity (84.8%), and the existence of early diastolic notch of UtA and MCA-PI were most specific in diagnosing adverse perinatal outcomes.

Conclusion

CPR-PI is a valuable indicator of adverse perinatal outcomes in PIH. Doppler studies of multiple vessels may help manage high-risk pregnancies as it may provide helpful information about the fetus at risk of hypoxia and placental insufficiency.

Associations of maternal age at the start of pregnancy with placental function throughout pregnancy: The Generation R Study

OBJECTIVE

To examine the associations of maternal age at the start of pregnancy across the full range with second and third trimester uterine and umbilical artery flow indices, and placental weight.

STUDY DESIGN

In a population-based prospective cohort study among 8271 pregnant women, we measured second and third trimester uterine artery resistance and umbilical artery pulsatility indices and the presence of third trimester uterine artery notching using Doppler ultrasound.

RESULTS

Compared to women aged 25-29.9 years, higher maternal age was associated with a higher third trimester uterine artery resistance index (difference for women 30-34.9 years was 0.10 SD (95% Confidence Interval (CI) 0.02 to 0.17), and for women aged ≥40 years 0.33 SD (95% CI 0.08 to 0.57), overall linear trend 0.02 SD (95% CI 0.01 to 0.03) per year). Compared to women aged 25-29.9 years, women younger than 20 years had an increased risk of third trimester uterine artery notching (Odds Ratio (OR) 1.97 (95% CI 1.30-3.00)). A linear trend was present with a decrease in risk of third trimester uterine artery notching per year increase in maternal age (OR 0.96 (95% CI 0.94 to 0.98)). Maternal age was not consistently associated with umbilical artery pulsatility indices or placental weight.

CONCLUSIONS

Young maternal age is associated with higher risk of third trimester uterine artery notching, whereas advanced maternal age is associated with a higher third trimester uterine artery resistance index, which may predispose to an increased risk of pregnancy complications.

Melatonin for prevention of placental malperfusion and fetal compromise associated with intrauterine inflammation-induced oxidative stress in a mouse model

Melatonin has been shown to reduce oxidative stress and mitigate hypercoagulability. We hypothesized that maternally administered melatonin may reduce placental oxidative stress and hypercoagulability associated with exposure to intrauterine inflammation (IUI) and consequently improve fetoplacental blood flow and fetal sequelae. Mice were randomized to the following groups: control (C), melatonin (M), lipopolysaccharide (LPS; a model of IUI) (L), and LPS with melatonin (ML). The expression of antioxidant mediators in the placenta was significantly decreased, while that of pro-inflammatory mediators was significantly increased in L compared to C and ML. The systolic/diastolic ratio, resistance index, and pulsatility index in uterine artery (UtA) and umbilical artery (UA) were significantly increased in L compared with other groups when analyzed by Doppler ultrasonography. The expression of antioxidant mediators in the placenta was significantly decreased, while that of pro-inflammatory mediators was significantly increased in L compared to C and ML. Vascular endothelial damage and thrombi formation, as evidenced by fibrin deposits, were similarly increased in L compared to other groups. Maternal pretreatment with melatonin appears to modulate maternal placental malperfusion, fetal cardiovascular compromise, and fetal neuroinflammation induced by IUI through its antioxidant properties.

Reference ranges for uterine artery pulsatility index during the menstrual cycle: a cross-sectional study

BACKGROUND

Cyclic endometrial neoangiogenesis contributes to changes in local vascular patterns and is amenable to non-invasive assessment with Doppler sonography. We hypothesize that the uterine artery (UtA) impedance, measured by its pulsatility index (PI), exhibits a regular pattern during the normal menstrual cycle. Therefore, the main study objective was to derive normative new day-cycle-based reference ranges for the UtA-PI during the entire cycle from days 1 to 34 according to the isolated time effect and potential confounders such as age and parity.

METHODS

From January 2009 to December 2012, a cross-sectional study of 1,821 healthy women undergoing routine gynaecological ultrasound was performed. The Doppler flow of the right and left UtA-PI was studied transvaginally by colour and pulsed Doppler imaging. The mean right and left values and the presence or absence of a bilateral protodiastolic notch were recorded. Reference intervals for the PI according to the cycle day were generated by classical linear regression.

RESULTS

The majority of patients (97.5%) presented unilateral or bilateral UtA notches. The crude 5th, 50th, and 95th reference percentile curves of the UtA-PI at 1-34 days of the normal menstrual cycle were derived. In all curves, a progressive significant decrease occurred during the first 13 days, followed by an increase and recovery in the UtA-PI. The adjusted 5th, 50th, and 95th reference percentile curves for the effects of age and parity were also obtained. These two conditions generated an approximately identical UtA-PI pattern during the cycle, except with small but significant reductions at the temporal extremes.

CONCLUSIONS

The median, 5th, and the 95th percentiles of the UtA-PI decrease during the first third of the menstrual cycle and recover to their initial values during the last two thirds of the cycle. The rates of decrease and recovery depend significantly on age and parity.

Doppler ultrasound evaluation in preeclampsia

Background

Worldwide preeclampsia (PE) is the leading cause of maternal death and affects 5 to 8% of pregnant women. PE is characterized by elevated blood pressure and proteinuria. Doppler Ultrasound (US) evaluation has been considered a useful method for prediction of PE; however, there is no complete data about the most frequently altered US parameters in the pathology. The aim of this study was to evaluate the uterine, umbilical, and the middle cerebral arteries using Doppler US parameters [resistance index (RI), pulsatility index (PI), notch (N), systolic peak (SP) and their combinations] in pregnant women, in order to make a global evaluation of hemodynamic repercussion caused by the established PE.

Results

A total of 102 pregnant Mexican women (65 PE women and 37 normotensive women) were recruited in a cases and controls study. Blood velocity waveforms from uterine, umbilical, and middle cerebral arteries, in pregnancies from 24 to 37 weeks of gestation were recorded by trans-abdominal examination with a Toshiba Ultrasound Power Vision 6000 SSA-370A, with a 3.5 MHz convex transducer. Abnormal general Doppler US profile showed a positive association with PE [odds ratio (OR) = 2.93, 95% confidence interval (CI) = 1.2 - 7.3, P = 0.021)], and a specificity and predictive positive value of 89.2% and 88.6%, respectively. Other parameters like N presence, RI and PI of umbilical artery, as well as the PI of middle cerebral artery, showed differences between groups (P values < 0.05).

Conclusion

General Doppler US result, as well as N from uterine vessel, RI from umbilical artery, and PI from umbilical and middle cerebral arteries in their individual form, may be considered as tools to determine hemodynamic repercussion caused by PE.

Transmission line models to simulate the impedance of the uterine vasculature during the ovarian cycle and pregnancy

OBJECTIVES

Changes in uterine vascular impedance may yield diagnostic insight into physiological and pathological changes in uterine vascular resistance and compliance during the ovarian cycle and pregnancy. Herein, our objectives were to develop models to simulate uterine vascular impedance in order to gain insight into the vascular size and stiffness changes that occur during ovarian cycling and pregnancy.

STUDY DESIGN

Two electrical analogue transmission line models were developed and evaluated based on goodness-of-fit to experimental impedance measurements, which were obtained in nonpregnant luteal and follicular phase (NP-L and NP-F) and pregnant (P) ewes (n=4-8 per group). First, an anatomically based, multi-segment, symmetric, branching transmission line model was developed. Parameter values were calculated based on experimental measurements of size and stiffness in the first three generations of the uterine arterial tree for NP-L, NP-F and P ewes. Then, a single segment transmission line model was developed and effective parameter values were optimized to best-fit the measured impedances.

RESULTS

The anatomically based multi-segment model did not yield the expected good agreement with the experimental data (R(2)<0.5 for all groups). In contrast, the impedance spectra predicted by the single segment model agreed very well with experimental data (R(2)=0.93, 0.82, and 0.84 for NP-L, NP-F and P, respectively; p<0.0001, all groups). Furthermore, the changes in the best-fit model parameters for NP-F and P compared to the NP-L were consistent with the prior literature on the effects of the ovarian cycle and pregnancy on vascular resistance and compliance. In particular, compared to NP-L, NP-F had decreased longitudinal and terminal resistance with a modest increase in compliance whereas pregnancy caused more dramatic drops in longitudinal and terminal resistance and a significant increase in compliance.

CONCLUSIONS

The single segment transmission line model is a useful tool to examine changes in vascular structure and function that occur during the ovarian cycle and pregnancy.

The effects of the ovarian cycle and pregnancy on uterine vascular impedance and uterine artery mechanics

OBJECTIVES

Uterine vascular resistance (UVR) is the ratio of systemic mean arterial pressure to mean uterine blood flow and is sensitive to changes in small arteries and arterioles. However, it provides little or no insight into changes in large, conduit arteries. Fluctuations in estrogen (E2) and progesterone (P4) levels during the ovarian cycle are thought to cause uterine resistance artery vasodilation; the effects on large arteries are unknown. Herein, our objective was to use the uterine vascular impedance, which is sensitive to changes in small and large arteries, to determine the effects of the ovarian cycle and pregnancy on the entire uterine vasculature.

STUDY DESIGN

Uterine vascular perfusion pressure and flow rate were recorded simultaneously in anesthetized sheep in the nonpregnant (NP) luteal (NP-L, n=6) and follicular (NP-F, n=7) phases and in late pregnancy (CP, n=10). Impedance and metrics of impedance (input impedance Z(0), index of wave reflection R(W), characteristic impedance Z(C)) were calculated. E2 and P4 levels were measured from jugular vein blood samples. Finally, from pressure-diameter tests post-mortem, large uterine artery circumferential elastic modulus (E(Circ)) was measured. Significant differences were evaluated by two-way ANOVA or Student's t-test.

RESULTS

As expected, E2:P4 was higher in the NP-F group compared to the NP-L group (p<0.05). Also as expected, UVR and Z(0) decreased in the follicular phase compared to the luteal (p<0.05), but R(W), Z(C), and E(Circ) were unaltered. Pregnancy not only substantially decreased UVR (and Z(0)) (p<0.00001) but also decreased Z(C) (p<0.001), R(W) (p<0.0001), E(Circ) (p<0.01), and pulse wave velocity (p<0.0001).

CONCLUSIONS

The E2:P4 ratio mediates resistance artery vasodilatation in nonpregnant states, but has no effect on conduit artery size or stiffness. In contrast, pregnancy causes dramatic vasodilation and remodeling, including substantial reductions in conduit artery stiffness and increases in conduit artery size, which affect pulsatile uterine hemodynamics.

Reference ranges for uterine artery mean pulsatility index at 11-41 weeks of gestation

OBJECTIVES

To construct gestational age (GA)-based reference ranges for the uterine artery (UtA) mean pulsatility index (PI) at 11-41 weeks of pregnancy.

METHODS

A prospective cross-sectional observational study was carried out of 20 consecutive singleton pregnancies for each completed gestational week at 11-41 weeks. UtAs were examined by color and pulsed Doppler imaging, and the mean PI, as well as the presence or absence of a bilateral protodiastolic notch, were recorded. Polynomials were fitted by means of least-square regression to estimate the relationship between the mean UtA-PI and GA.

RESULTS

A total of 620 women were included. A second-degree polynomial (Log(e) mean UtA-PI = 1.39 - 0.012 x GA + GA(2) x 0.0000198, with GA measured in days), after a natural logarithmic transformation, was selected to model our data. There was a significant decrease in the mean UtA-PI between 11 weeks (mean PI, 1.79; 95(th) centile, 2.70) and 34 weeks (mean PI, 0.70; 95(th) centile, 0.99). It then became more stable up until 41 weeks (mean PI, 0.65; 95(th) centile, 0.89).

CONCLUSIONS

The mean UtA-PI shows a progressive decrease until the late stages of pregnancy. Reference ranges for mean UtA-PI may have clinical value in screening for placenta-associated diseases in the early stages of pregnancy, and in evaluating patients with pregnancy-induced hypertension and/or small-for-gestational age fetuses during the third trimester.

Color and pulsed Doppler sonography for arterial bleeding detection

OBJECTIVE

Hemorrhage resulting from penetrating injuries in the extremities is the leading cause of preventable death in the modern battlefield. Development of methods for detection and localization of vascular bleeding is needed that could be applied emergently without special training outside the hospital setting. Our objective was to assess whether Doppler sonography can provide quantitative parameters that characterize the bleeding site in the extremities.

METHODS

Twenty-four rabbit femoral arteries (diameter of approximately 1 mm) were punctured transcutaneously with an 18-gauge needle. Doppler interrogations were performed at 5 locations in the injured vessels (site of injury, distal and proximal locations relative to the injury, and neck and tip of the bleeding jet).

RESULTS

Compared with the normal signals obtained before the vessel was punctured, pulsed Doppler observations of the injury site showed a statistically significant increase in the systolic and diastolic velocities (systolic: mean +/- SD, 30.1 +/- 12.5 cm/s [injury] versus 15.1 +/- 4.2 cm/s [normal]; diastolic: 17.8 +/- 6.5 cm/s [injury] versus 0.7 cm/s [normal]). Similar increases in velocities were observed at the neck of the bleeding jet, whereas the tip of the bleeding jet showed venouslike patterns. These patterns are unique only at the bleeding site. Color Doppler observations showed turbulence (in the form of checkered color patterns) localized at the injury site.

CONCLUSIONS

Our results indicate that both color and pulsed Doppler sonography can be used to accurately localize the site of injury, which may facilitate application of hemorrhage control therapies in battlefield situations.

Abnormal Doppler velocimetry is related to adverse perinatal outcome for borderline amniotic fluid index during third trimester

AIM

To evaluate the relationship between abnormal Doppler velocimetry and adverse perinatal outcomes in pregnancies with borderline amniotic fluid index (AFI).

METHODS

Medical records of 3740 pregnancies with known AFI and Doppler velocimetry measurements within 2 weeks of delivery, and delivered between January 1996 and December 2003, were retrospectively analyzed. Borderline AFI was defined as 5 cm < AFI < or = 8 cm. For the umbilical artery, Doppler velocimetry was considered abnormal when the S/D ratio was greater than 3.0 or when end-diastolic flow was absent; whereas, for the uterine artery, the S/D ratio was greater than 2.6 or presence of end-systolic notch was defined as abnormal. Adverse perinatal outcomes (small for gestational age, cesarean section for fetal distress, 5 min Apgar score of less than 7, respiratory distress syndrome, NICU admission, and perinatal death) according to Doppler velocimetry in borderline AFI were evaluated.

RESULTS

Compared to the normal AFI group (n = 3523), the borderline AFI group (n = 217) had significantly higher incidence of adverse perinatal outcome (28.8% vs 54.8%). There was 3-fold increase in the incidence of adverse perinatal outcome among women with the borderline AFI in comparison to normal AFI (OR, 3.00; CI, 2.27-4.00). When abnormal Doppler velocimetry was associated with borderline AFI, a 5-fold increase in the incidence of adverse perinatal outcome was noted (OR, 5.26; CI, 3.00-9.21).

CONCLUSION

In the borderline AFI group, the presence of abnormal Doppler velocimetry measurement was related to increased risk of adverse perinatal outcome. Thus, borderline AFI of 5-8 cm, especially when associated with abnormal Doppler velocimetry, mandates closer antenatal surveillance.

Prognostic value of uterine artery Doppler velocimetry in growth-restricted fetuses delivered near term

OBJECTIVE

We have investigated the use of uterine artery Doppler waveform analysis in growth restricted fetuses delivered at > or =34 weeks.

STUDY DESIGN

Included in the study were all consecutive euploid non-malformed singleton fetuses with accurate dating diagnosed as growth restricted (sonographic abdominal circumference <10th percentile) between January 1995 and December 1998 and who were delivered at > or =34 weeks. Delivery was expedited for biophysical profile 6 or less with nonreactive nonstress test, preeclampsia, oligohydramnios, absent fetal growth over 2 weeks, absent or reversed diastolic flow in the umbilical artery (UA), or UA pulsatility index (PI) greater than the 95th percentile after 37 weeks. Neonatal outcomes were compared in cases with normal versus abnormal Doppler waveforms at the uterine arteries (defined as average resistance index >0.58 or presence of bilateral notching) using one-way analysis of variance, chi(2) test, and logistic regression analysis. A two-tailed P <.05 or an odds ratio (OR) with 95% CI not inclusive of the unity was considered significant.

RESULTS

Growth-restricted fetuses with abnormal (n = 109) versus normal (n = 185) Doppler velocimetry results at the uterine arteries had similar ratios of head-to-abdominal circumference at diagnosis, but asymmetric body proportion at the last scan before delivery. Neonates of mothers with abnormal uterine artery Doppler waveforms were more frequently born of cesarean delivery, particularly for non-reassuring fetal testing (27% vs 10%, P <.001), had significantly lower gestational age at delivery (37.7 +/- 2.0 vs 38.8 +/- 1.6, P <.001), and lower birth weight percentiles (4.8 +/- 5.1 vs 9.3 +/- 10.2, P <.001). More importantly, although 5-minute Apgar scores and UA pH values were not significantly lower, they had a significantly greater risk of admission to intensive care unit for reasons other than low birth weight alone (36% vs 11%). After preeclampsia was controlled, such risk was associated with an OR of 4.1 (95% CI 2.2-7.5).

CONCLUSION

In growth-restricted fetuses delivered at > or =34 weeks, presence of abnormal Doppler waveforms at the uterine arteries at diagnosis is associated with a 4-fold increased risk of adverse neonatal outcome.