Introduction
Pregnancy related pre eclampsia is the condition with no certain etiology and
involves different physiological processes. The pathological reasons
of pre eclampsia is still under
investigations. Conversely, it is supposed to arise in two stages. Stage one
incorporate the confined placental low oxygen supply and waning of fetal trophoblastic invasion of the decidua.
Another stage which is second stage, in which release of different blood
related factors ,like angiogenic and pro inflammatory
manisfestation occurs in blood of pregnant female (Albu et al.,
2014). Pre eclampsia
is commonly categorized by raised blood pressure and protein urine, with the
medical demonstration generally happening through the mid of second trimester
or third trimester of pregnancy and relapsing after delivery. This comprises of
two chief categories: initial-commencement pre eclampsia(arising before
thirty four weeks of gestation) and late-commencement of pre eclampsia (arising afterward thirty four weeks of
gestation) . Even though the donating structures of initial- and late-onset pre
eclampsia might overlay, early-onset pre eclampsia is related through improved odds of difficulties,
predominantly ,baby born before forty weeks, growth of
baby restraint and maternal indisposition and death equated to late onset pre eclampsia (Litwinska et al., 20017). The definition
of intrauterine growth restriction is a fetur growth
not as much of the
normal growth prospective of a definite infant because of hereditary or
conservational reasons. The terms IUGR and Small for Gestational Age (SGA) are
frequently cast-off to label the similar problem, even though here are refined
differences among the two. SGA is identified as birth weight
less than 10% intended for that specific gestational age, parity and gender
the population standards on the growth chart. IUGR is a clinical description
and practical to new borns with clinical suggestions
of malnourishment (Cnossen et al., 2008; malik et al., 2020).
Hypothetically, a
uncontrolled upsurge in the vascular resistance of plecenta
must stay measureable from the uterine arteries doppler
ultrasonography and also measuring PI values, it
might be compromise the prospective to identify the different abnormal
conditions related to pregnancy like preeclampsia and IUGR (Turk et al., 2019). Operative showing intended for preeclampsia may be
accomplished from amount of the pulsatility index of
uterine artery in doppler ultrasound eleven to
thirteen weeks' gestation, cast-off in grouping of motherly history,
hypertension, Identification of plasma protein A in and restrictive growth of plecenta. Aimed at, a false‐positive degree of 5%, that one has remained measured from
the novel shared technique of showing may expect around 90% of medical cases of
PE demanding to give birth previously 34 weeks and 45% of cases of late‐onset pre‐eclampsia
or uterine artery PI dimension, the pregnancy should be among 11 + 0 and 13 + 6
weeks. Transabdominal ultrasound must be cast-off to
attain a midsagittal section of the uterus and
cervical canal. The internal cervical OS might be recognized and the transducer
skewed gradually from side to side in each paracervical
area, by means of color flow mapping, to recognize the uterine arteries as
aliasing vessels flowing laterally the side of the cervix and uterus (MacDonald and
McCarthy, 2015). Technique used to achieve
waveform flow velocity which is coming form the
ascending division of the uterine artery is pulsed wave doppler. After successive achieving mean from three
values or three similar waveforms are gotten, the pulsatality
index might be stately and calculated and the overall pulsatility
index of the left and right arteries calculated. or
uterine artery pulse index measurement, the gestational age necessity be
between 11 + 0 and 13 + 6 weeks. Transabdominal
ultrasound would be used to acquire a midsagittal
section of the uterus and cervical canal. The internal cervical OS would be
recognized and the transducer tilted softly from side to side in each paracervical area, by means of color flow mapping, to
recognize the uterine arteries as aliasing vessels flowing lengthways the side
of the cervix and uterus (Ciobanu et al., 2019). Doppler ultrasound of
pulsed wavefroms might be binding-off for achieving the velocity of
waveforms from the branch which is coming uterine artery and giving ascending
branches at the point closest to the internal os.
When three similar consecutive waveforms were gotten, the PI which should be
dignified and the mean PI of the left and right arteries were calculated as 4,
7. In this study, we determine uterine artery doppler indices as predictive measures for the
preeclampsia and intrauterine growth restriction (Turk et al., 2019; Malik et al., 2018; Pialis et al.,
2007). In this study, we determine uterine artery doppler indices as predictive measures for the
preeclampsia and intrauterine growth restriction.
Objective
To determine
uterine artery doppler
indices as predictive measures for the preeclampsia and intrauterine growth
restriction.
Methodology
A longitudinal study design was used. Data was collected from the
pregnant females. Non probability purposive sampling technique was used in this
study. Sample size was 162 with 5% precision level. In inclusion Criteria
pregnant females of aged between 18 to 40 years and having 18 to 30 weeks of
gestation were included. Those pregnant females who had diabetes or
hypertension before pregnancy or females who had fetal anomaly were excluded in
our study. Uterine artery ultrasound were done by color Doppler power vision
with 4 MHz convex array transduce and early diastolic
notches from both sides were recorded and after that on follow up round blood
pressure and protein urine sample were collected to see the presence of proteinuria to detect preeclampsia. Data was collected from
162 participants through a self made questionnaire and it was purposive
approach for collecting samples. Data was entered in SPSS version 22 and graphs
were formulated afterwards.
Results
Table
1. Descriptive
statistics of Age
|
Age |
Frequency |
Percent |
|
18 to 29 years of age |
69 |
42.6 |
|
29 to 40 years of age |
93 |
57.4 |
|
Total |
162 |
100 |
The
table 1 shows that the 42.6% females are in age group of 18 to 29 years and 57.4% females
are
in age group of 29 to 40 years.
Table 2. Descriptive statistics of Notch
|
Notch |
Frequency |
Percent |
|
Right notch |
19 |
11.7 |
|
Left notch |
15 |
9.3 |
|
Bilateral notch |
21 |
13.0 |
|
No notch seen |
107 |
66.0 |
|
Total |
162 |
100 |
The
table 2 analysis shows that the 11.7% USG shows right notch, 9.3 shows left
notch and 13% USG of pregnant females shows bilateral notch. Remaining 66%
shows no notch during USG of gestation period between 18 to 30 weeks.
Table
3. Descriptive
statistics of Gestational Age
|
Gestation weeks |
Frequency |
Percent |
|
18 to 24 weeks |
93 |
57.4 |
|
24 to 30 weeks |
69 |
42.6 |
|
Total |
162 |
100 |
The table 3
analysis shows that the USG performed in 57.4% females having gestation period
between 18 to 24 weeks and remaining 42.6% had 24 to 30 weeks of gestation.
Table
4. Descriptive
statistics of Proteinuria after 30 weeks of Pregnancy
|
Proteinuria |
Frequency |
Percent |
|
Present |
54 |
33.3 |
|
Not Present |
108 |
66.7 |
|
Total |
162 |
100 |
The table 4
analysis shows that 33.3% had proteinuria after 30
weeks.
Table 5.
Descriptive statistics of BP
|
BP after 30 weeks |
Frequency |
Percent |
|
More than 140/90 |
55 |
34 |
|
Less than 140/90 |
107 |
66.0 |
|
Total |
162 |
100 |
The table 5 analysis shows that 34% females having high BP at different
times and remaining 66% shows normal BP reading of both systolic and diastolic.
This variable is related to diagnoses of preeclampsia.
Table 6.
Descriptive statistics of Preeclampsia
|
Pre Eclampsia |
Frequency |
Percent |
|
Yes |
53 |
32.7 |
|
No |
109 |
67.3 |
|
Total |
162 |
100 |
The table 6
analysis shows 32.7% females had pre eclmapsia after
30 weeks of gestation.
Table 7. Descriptive statistics of IUGR
|
IUGR |
Frequency |
Percent |
|
Yes |
32 |
19.8 |
|
No |
130 |
80.2 |
|
Total |
162 |
100 |
Results
of the following study demonstrate the accuracy of the assessment of Notch and Pulsatility Index among the pregnant females reporting for Intrauterine growth restriction (IUGR) and preeclampsia.
Findings of the study suggested both parameters to be quite sensitive in
stating if the female is undergoing IUGR or not (Table 7). After finding the
area under curve (AUC) among the parameters the results show values of 0.935
and 0.858 (Figure 1) for Notch and Pulsatility index
respectively. Moreover, contingency table was drawn among the Notch-IUGR and Pulsatility index-IUGR to state negative predictive
variable (NPV), positive predictive variable (PPV), Sensitivity and Specificity
of Notch and Pulsatility index for the occurrence of
IUGR. Negative predictive variable and positive predictive variable (NPV and
PPV) of the Notch and pulsatility index expresses the
higher accuracy of the Notch over the pulsatility index
in determining the intrauterine growth restriction (IUGR) (Tables 8 and 9). The
PPV and NPV (Table 10) for both variables were recorded as (36%, 99%) and (30%,
99%) respectively. Similarly, both the parameters express to be equally
sensitive in the determination of IUGR with sensitivity of 95% whereas, as far
as specificity is concerned pulsatility index
expressed 66% and Notch was 75% (Table 11) specific in the determination of the
said condition. Thus, it can be said that Notch determination is quite more
specific and sensitive for the determination of intrauterine growth restriction
(IUGR).
Figure 1. The are
under curve for sensitivity and specificity
Table 8. Contingency table of Notch with IUGR
|
|
IUGR |
|||
|
YES |
NO |
Total |
||
|
NOTCH |
YES |
20 True
Positive |
35 False
Positive |
55 |
|
NO |
1 False
Negative |
106 True
Negative |
107 |
|
|
Total |
21 |
141 |
162 |
|
PPV=
a/a+b= 20/20+35=0.3636
NPV=d/c+d=106/106+1=0.99
Specificity=d/d+b=106/106+35=0.75
Sensitivity=a/a+c=20/20+1=0.952
Table 9:
Contingency table of PI with IUGR
|
|
IUGR |
|||
|
YES |
NO |
TOTAL |
||
|
PI |
YES |
20 True
Positive |
47 False
Positive |
67 |
|
NO |
1 False
Negative |
94 True
Negative |
95 |
|
|
TOTAL |
21 |
141 |
162 |
|
PPV=
a/a+b= 20/20+47=0.298
NPV=d/c+d=94/94+1=0.989 Specificity=d/d+b=94/94+47=0.666
Sensitivity=a/a+c=20/20+1=0.952
Table
10. Contingency
Table showing PPV and NPV of Notch vs PI
|
|
PPV |
NPV |
|
NOTCH |
36% |
99% |
|
PI |
30% |
99% |
Table 11:
Estimation of specificity and sensitivity among ratios (Notch and PI)
|
|
Sensitivity |
Specificity |
|
NOTCH |
95% |
75% |
|
PI |
95% |
66% |
Discussion
A
condition characterized by increases blood pressure during the pregnancy and
followed by organ perfusion with extreme vascular spasm is known as
preeclampsia (Ciobanu et al., 2019; Pialis et al., 2007). Preeclampsia causes many complications and death of
pregnant mothers in developing areas of the world and Organization of world
health WHO estimated that more than ten lacs pregnant
women die from this condition (Damodaram et al., 2010). However, Incidence of
preeclampsia influenced by race ethinicity and
hereditary and genetic changings and most of the
young females and nulliparous women suffering from
this condition (Yamaleyeva et al., 2017). There is a non invasive technique which is used for
detecting this condition by uterus-plecental blood
flow, called Uterine artery Doppler ultrasonography (Finn-Sell et al., 2018). Most of the researches shows that notch shows in ultrasonography in second trimester was effective in
diagnosis that condition and our study also shows that this is somehow this is
true because our results also predicts that, preeclampsia happened in those
women in which notch was seen (Harman
and Baschat, 2003). For the evaluation of the
prognostic uterine artery values of doppler
usage in the prevalence of PE and intrauterine growth discussing to the
obstetric department of Bahria Hospital. A
prospective cohort study, Hundred eight pregnant females with mean age of
twenty eight years goes for uterine artery Doppler ultrasound at second trimester
of pregnancy. A research conducted by Turk et
al., (2019) who have selected hundred pregnant females and their uterine
artery doppler ultrasound was performed, average age
of females were 23.2 from 11 to 14 and 21 to 24 of gestational weeks. In one more
research done by Dehghani-Firouzabadi uterine artery
Doppler ultrasonography was conducted at fourteen to
sixteen weeks of pregnancy (Caradeux et al., 2019; Seyam
et al., 2002) and in our study ultrasonography was conducted between eighteen to thirty weeks
than blood pressure and proteinuria checked to assess
preeclampsia. Correspondingly, Anastasaks et al.,
(2008) study incidence of preeclampsia from twenty three to twenty five weeks
of gestation and they performed intra vaginal uterine artery doppler ultrasound technique rather than trans abdominal
method but , a fabricated on the follow-up examination
of 162 pregnant ladies of the our study, 34% pregnant females were diagnosed
with severe and non-severe hypertension, but no sign of gestational
hypertension was observed in the other 66% of
pregnant females. In relations of devising proteinuria,
33.3% pregnant females diagnosed by urine examination, correspondingly and
66.7% pregnant females, and urine samples were free from protein content was seen
during pregnancy and this was made a relationship with preeclampsia. Turk et
al., (2019) done a research of this topic and he evaluate that ten pregnant
females of second or third trimester of pregnancy from the studied population
diagnosed with PE from all of these two diagnosed from severe and eight
pregnant females diagnosed with mild preeclampsia, correspondingly (Berkely et al.,
2012; Azhar et al., 2020). For the prevention of high
risk pregnancy related complications which as intrauterine growth restriction,
intrauterine fetal deaths and also PE
,uterine artery doppler ultrasonography
which is performed at 18 and 22 weeks of
gestation might be useful as an appropriate method for diagnosis (Janwantanakul et
al., 2008).
Conclusion
In
this research we concluded that, preeclampsia and intrauterine growth
restriction have relatively low incidence. From the results of our research, we
have seen notching whatever on right ,left or bilateral and pulsatility
index are these diagnostic parameters to
evaluate these complications before getting worse and uterine artery doppler ultrasound should be perform in every obstetric
visit during pregnancy. Although the results vary according to risk factors of
different pregnant females but in our results, we clearly found that there
uterine artery Doppler predict pre eclampsia and IUGR
in those women who had shown notches in their USG and after thirty weeks
several tests and BP reading told us that uterine artery Doppler was good
predictive measure, we also seen abnormal uterine artery waveforms are a better
predictor of pre-eclampsia than of intrauterine
growth restriction. We also concluded that pulsatility
index, had also more than normal values in those pregnant females who has
notches and those pregnant females,their ultrasound
shows no notches ,their PI values are normal,so we
can coorelate this variable that both have
significant values. In future research should also concentrate on combining
uterine artery Doppler ultrasonography with different
tests like proteinuria because these factors also
correlates with assessing complications.
Recommendation
Routine BP monitoring should be done at
primary health center and should be referred to tertiary center early if any
intervention is required.
Administration of low dose aspirin
increased calcium intake, antioxidant and nitric oxide usage can be instituted
to prevent or arrest the progress of the disease and improve maternal and
neonatal outcome.
Acknowledgments
I am thankful to Almighty Allah, the
most beneficent and the most merciful and the Holy Prophet (P.B.U.H) for
blessings upon me and giving me the courage and wisdom to complete this
research successfully. I am very much indebted to my supervisor whose content
supervision and instructions made me expeditious in my achievements. I also
wish to say big thank to biostatistician for his guidance and help in every
step of research work and all the teachers at radiology department UOL for
their cooperation and for making me a better person throughout my degree. I
would like to thank from bottom of my heart to Head of Department) for having
faith in me and provides me an opportunity to study under his supervision and
inspired and to believe in myself.
Conflict of interest
The
authors declare absence of any conflict of interest.
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