The use of fetal Doppler in obstetrics.

OBJECTIVE

To develop national guidelines on the use of fetal Doppler in obstetrics.

OPTIONS: Whether umbilical cord artery, umbilical cord venous, ductus venosus, and middle cerebral artery Doppler are useful in assessing fetal health.

OUTCOME: Prediction of adverse perinatal outcome or prediction of fetal anemia.

EVIDENCE: MEDLINE search and review of bibliographies in identified articles.

VALUES: The evidence was reviewed by the Diagnostic Imaging Committee and the principal authors. A quality of evidence assessment was undertaken as outlined in the report of the Canadian Task Force on the Periodic Health Examination.

BENEFITS, HARMS, AND COSTS: Intrauterine growth restriction complicates 5% to 10% of all pregnancies and up to 30% of multiple pregnancies. In 60% of these pregnancies, the primary cause is placental insufficiency. Improvement in the identification of the fetus at risk of intrauterine demise may lead to more successful management strategies. Management of fetal red blood cell isoimmunization requires a prediction of fetal anemia. If invasive procedures to predict fetal anemia can be replaced with noninvasive tests, fetal morbidity and mortality can be reduced.

RECOMMENDATIONS: 1. Umbilical artery Doppler should be available for assessment of the fetal-placental circulation in pregnant women with suspected severe placental insufficiency. (I-A) 2. Depending on other clinical factors, reduced, absent, or reversed umbilical artery end-diastolic flow is an indication for enhanced fetal surveillance or delivery. If delivery is delayed to enhance fetal lung maturity with maternal administration of glucocorticoid, intensive fetal surveillance until delivery is suggested for those fetuses with reversed end-diastolic flow. (II-1B) 3. Umbilical artery Doppler should not be used as a screening tool in healthy pregnancies, as it has not been shown to be of value in this group. (I-A) 4. Umbilical venous double pulsations, in the presence of abnormal umbilical artery Doppler waveforms, necessitate a detailed assessment of fetal health status. (II-3B) 5. Measurement of the fetal middle cerebral artery Doppler peak systolic flow velocity is a predictor of moderate or severe fetal anemia and can be used to avoid unnecessary invasive procedures in pregnancies complicated with red blood cell isoimmunization. (II-1A) 6. Since inaccurate information concerning fetal Doppler studies could lead to inappropriate clinical decisions, it is imperative that measurements be undertaken and interpreted by expert operators who are knowledgeable about the significance of Doppler changes and who practise appropriate techniques. Duplex mode with pulsed Doppler and colour Doppler flow mapping is the minimum required ultrasound equipment. (II-1A)