|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2022 | Volume
: 3
| Issue : 1 | Page : 13-20 |
|
Fetal doppler velocimetry of the middle cerebral artery in hypertensive disorders of pregnancy, in Kano, Nigeria
Abdullahi Dahiru1, Yahuza Mansur Adamu2, Kabiru Isyaku2, Anas Ismail2, Yusuf Lawal2, Murtala Yusuf3
1 Department of Radiology, Muhammadu Abdullahi Wase Hospital,Kano, Nigeria
2 Department of Radiology, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Obstetrics and Gynecology, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
| Date of Submission | 13-Oct-2021 |
| Date of Decision | 14-Dec-2021 |
| Date of Acceptance | 05-Jan-2022 |
| Date of Web Publication | 07-Jul-2022 |
Correspondence Address:
Yahuza Mansur Adamu
Department of Radiology, Bayero University, Aminu Kano Teaching Hospital, Kano
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jrmt.jrmt_22_21
Background: Hypertension is one of the leading causes of maternal and fetal mortality and morbidity. The middle cerebral artery (MCA) is the major supplier of blood to the brain. Doppler velocimetry has made it possible to identify and insonate the fetal MCA and is used in fetal surveillance in high-risk pregnancies and has been efficacious in antenatal fetal monitoring. Materials and Methods: Sixty-five patients with hypertensive disorders of pregnancy and 65 normotensive pregnant controls between 20 and 39 weeks of gestational age were recruited for this study. Obstetric ultrasound scan was done to determine the gestational age, estimated fetal weight, and amniotic fluid indices. Fetal MCA Doppler velocimetric indices (peak systolic velocity [PSV], end-diastolic velocity [EDV], (RI) Resistivity index RI-resistivity index, pulsatility index [PI], and systolic/diastolic ratio [S/D ratio]) were also measured and documented. Results: The mean PSV of the study group (32.1 ± 10.1 cm/s) was lower than that of the control group (38.6 ± 9.3 cm/s). This difference was not statistically significant (P = 0.416). However, the mean EDV of the study group (9.09 ± 2.9 cm/s) was higher than that of the control group (8.6 ± 2.0 cm/s) which was also not statistically significant (P = 0.074). There was a statistically significant difference (P ≤ 0.001) between the mean RI of the study group (0.70 ± 0.10) and that of the control group (0.77 ± 0.05). The mean PI of the study group (1.35 ± 0.5) was also lower than that of the control group (1.49 ± 0.3), which was statistically significant (P ≤ 0.001). There was also a statistically significant difference (P = 0.003) between the mean S/D ratio of the study group (3.64 ± 1.4) and that of the control group (4.5 ± 1.1). Conclusion: There was a significant statistical difference in the fetal MCA Doppler velocimetric indices between hypertensive and normotensive groups indicating that fetal MCA Doppler ultrasound is a useful tool in monitoring the hemodynamic changes in the cerebral circulation of fetuses of mothers with hypertension in pregnancy.
Keywords: Doppler, hypertension, middle cerebral artery
How to cite this article:
Dahiru A, Adamu YM, Isyaku K, Ismail A, Lawal Y, Yusuf M. Fetal doppler velocimetry of the middle cerebral artery in hypertensive disorders of pregnancy, in Kano, Nigeria. J Radiat Med Trop 2022;3:13-20 |
How to cite this URL:
Dahiru A, Adamu YM, Isyaku K, Ismail A, Lawal Y, Yusuf M. Fetal doppler velocimetry of the middle cerebral artery in hypertensive disorders of pregnancy, in Kano, Nigeria. J Radiat Med Trop [serial online] 2022 [cited 2023 Jun 3];3:13-20. Available from: http://www.jrmt.org/text.asp?2022/3/1/13/350085 |
| Introduction | |  |
Hypertensive disorders of pregnancy represent a group of conditions associated with high blood pressure (BP) during pregnancy, proteinuria, and in some cases, convulsions.[1] Hypertensive disorders complicating pregnancy are common and form a deadly triad along with hemorrhage and infection, which contribute greatly to maternal mortality and morbidity.[2] Hypertensive disorders accounted for 29.2% of all cases of medical disorders in pregnancy, and 18% of all fetal deaths are associated with hypertension.[3]
There are four categories of hypertension in pregnancy: chronic hypertension, gestational hypertension, preeclampsia and eclampsia, and preeclampsia superimposed on chronic hypertension.[4] In Nigeria, the prevalence of hypertensive disorders in pregnancy is about 10%.[5]
Recent studies confirm the efficacy of middle cerebral artery (MCA) Doppler assessment and advocate it.[6] Its indices provide important information on the hemodynamics of the vascular area under study. MCA Doppler measurement is a well-known modality for detecting fetal compromise.[7] Today, with the advancement of pulsed and color-coded Doppler ultrasound combined with better reproducibility, the MCA has emerged as the vessel of choice in the Doppler assessment of fetal intracranial circulation.[8] Evaluation of Doppler waveform of the MCA can predict most of the at-risk fetuses in high-risk pregnancies. Circulatory changes, reflected in certain fetal Doppler waveforms, can predict adverse perinatal outcome.[9]
This study is intended to determine the velocimetric pattern of fetal MCA in patients with hypertensive disorders in pregnancy as well as their spectral waveform pattern and compare them with the indices from normal controls.
| Materials and Methods | | |
This was a cross-sectional, hospital-based prospective study that recruited 65 pregnant subjects with history of diagnosed HDP (High Blood Pressure) between gestational ages of 20 and 40 weeks from the antenatal clinic as the study group. Sixty-five gestational age-matched pregnant women with normal BP were also recruited from routine antenatal clinic to constitute the control group at Aminu Kano Teaching Hospital, Kano, North Western Nigeria, from April 2015 to March 2016. Informed consent was obtained from the subjects.
All subjects with BP of or >140/90 mmHg and pregnant women whose systolic BP exceeds 30 mmHg or diastolic BP exceeds 15 mmHg above the recorded booking BP with singleton fetus within the gestational age 20–40 weeks were included in the study. Whereas pregnant women <20 weeks and >40 weeks of gestation, nonconsenting individuals, and those with presence of maternal diseases such as diabetes mellitus, chronic renal disease, multiple pregnancy, and fetal malformation were excluded for both groups.[10] For the control group, all normal pregnant women between 20 to 40 weeks of normal gestation were included.
After documenting the age, parity, clinical history, and gestational age of the subjects, BP of the subjects was measured using mercury sphygmomanometer and stethoscope. DC-6 Mindray (Biomed Electronics, Shenzhen, China, 2007) ultrasound machine was used. Transabdominal obstetric ultrasound scan was then done to determine the lie, presentation, viability of the fetus, and gestational age of the pregnancy in the subjects using a 3.5-MHz transducer to measure a combination of two or more of the following parameters: biparietal diameter, femur length, head circumference, and abdominal circumference.[11] Other obstetric measurements such as amniotic fluid index (AFI) and estimated fetal weight (EFW) were determined using appropriate anthropometric measurements.
The fetal MCA Doppler was examined using a 3.5-MHz linear transducer to insonate the MCA through the fetal head using grayscale and Doppler ultrasound. A transverse view of the fetal brain including the thalami and sphenoid bone wing was obtained and magnified. Using color flow imaging, the circle of Willis was first identified as tubular, color fillings within the fetal brain anterior to the cerebral peduncles with three major vessels seen anterior, posterior, and laterally. The MCA was appreciated as a major lateral branch of the circle of Willis, running anterolaterally at the borderline between the anterior and the middle cerebral fossae usually colored red due to flow toward the transducer. The MCA is a paired vessel. The contralateral MCA was seen as tubular color fillings with flow away from the transducer and colored blue. The MCA close to the transducer (anterior) was interrogated. The pulsed Doppler sample gate was then placed on the middle portion of this vessel to obtain flow velocity waveforms. The sample volume used was 2–3 mm in width. The velocity waveforms were recorded 2 mm from the origin of the vessel from the internal carotid artery. The angle between the ultrasound beam and the MCA was between 0° and 20°. The fetuses were examined in the episodes without breathing or minimal gross fetal movements.[12]
To ensure accuracy, a spectral Doppler tracing of at least five consistent cardiac cycles was frozen on the screen of the machine for consistent measurement of parameters. During the study, care was taken to apply minimal pressure to the maternal abdomen with the transducer, as fetal head compression is associated with alterations of intracranial arterial waveforms.[13] One cursor was placed at the highest point of the wave to get the peak systolic velocity (PSV) and another cursor was placed at the lowest point of the wave to get the end-diastolic velocity (EDV). The RI, pulsatility index (PI), and systolic/diastolic ratio (S/D ratio) were generated automatically from the ultrasound machine.[14]
Data collected were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 17.0 (SPSS Inc., IBM, Armonk, NY, USA). The PSV, EDV, resistive index (RI), PI, S/D ratio, biodata, and obstetric parameters of the hypertensive and normotensive pregnant women were recorded. Variables were presented as mean ± standard deviation. P < 0.05 was considered to be statistically significant. Student's t-test was used to test the difference in means between variables. Regression analysis was used for evaluation of correlation between indices and gestational age and; between the indices and BP. Findings were presented numerically, graphically, and in tabular form.
| Results | | |
A total of 130 patients comprising 65 pregnant hypertensive patients and 65 gestational age-matched controls were studied [Figure 1]. The ages of the study group ranged from 22 to 43 years with a mean of 31.9 ± 5.1 years, while the ages of the control group ranged from 20 to 43 years with a mean age of 27.8 ± 4.4 years. Four groups: 20-24 years, 25-29 years, 30-34 years and 35-39 years. The modal group among the hypertensive patients was 30–34 years and 24–29 years among the control group [Figure 2]. However, there was no statistically significant difference between the mean ages of the study and control groups (P = 0.156) [Table 1]. The parity of the study group ranged from 0 to 11 with a mean of 4.1 ± 2.7, while the parity of the control group ranged from 0 to 10 with a mean of 2.78 ± 2.0. There was a statistically significant difference between the mean parity of the study and control groups (P = 0.002) [Table 1]. | Table 1: Mean values of demographic and clinical indices of control and hypertensive groups
Click here to view |
 | Figure 2: Bar chart showing the mean gestational age distribution among the respondents
Click here to view |
The systolic BP of the study group ranged from 140 to 200 mmHg with a mean of 157 ± 13.8 mmHg, while the systolic BP of the control group ranged from 90 to 130 mmHg with a mean of 111 ± 8.8 mmHg. There was a statistically significant difference between the mean systolic BP of the study and control groups (P = 0.004). There was also a statistically significant difference between the mean diastolic BP of the study and control groups (P = 0.001). The diastolic BP of the study group ranged from 91 to 120 mmHg with a mean of 96 ± 11.0 mmHg, while the diastolic BP of the control group ranged from 60 to 90 mmHg with a mean of 77.5 ± 6.6 mmHg [Table 1].
The gestational age of the fetuses of the study group ranged from 20 to 39 weeks with a mean of 32.4 ± 4.9 weeks, while the gestational age of fetuses of the control group ranged from 20 to 39 weeks 46 with a mean gestational age of 32.1 ± 5.0 weeks [Figure 3]. There was no statistically significant difference between the mean gestational age of the study and control groups (P = 0.736). The patients in the study group were classified into four groups based on gestational age: 20–24 weeks, 25–29 weeks, 30–34 weeks, and 35–39 weeks of gestational age. Majority of the patients belong to the 35–39 weeks of gestational age (50.7%). The patients in the control group were matched for gestational age with the patients in the study group [Table 2].
The EFW of the fetuses of the study group ranged from 0.34 to 3.78 kg with a mean of 2.1kg ± 0.9 kg. The EFW of the fetuses of the control group ranged from 0.34 to 3.5 kg with a mean of 2.1 ± 0.98 kg. The difference between the mean EFW of the study and control groups was not statistically significant (P = 0.125) [Table 1].
There is a statistically significant difference between the mean amniotic fluid indices of the study and control groups (P = 0.002) [Table 1]. The amniotic fluid indices (AFI) of the study group ranged from 7.5 to 19.7 with a mean of 13.75 ± 2.73, while the AFI of the fetuses of the control group ranged from 10.5 to 19.2 with a mean of 14.9 ± 1.9.
The PSV of the study group ranged from 17.75 to 53.15 cm/s with a mean of 32.1 ± 10.1 cm/s, while the PSV of the control group ranged from 22.68 to 58.18 cm/s with a mean of 38.6 ± 9.3 cm/s [Figure 4]. There was no statistically significant difference between the mean PSV of the study and control groups (P = 0.416) [Table 3]. There was no statistically significant difference between the mean EDV of the study and control groups (P = 0.074) [Table 3]. The EDV of the study group ranged from 3.61 to 21.26 cm/s with a mean of 9.09 ± 2.90, while the EDV of the control group ranged from 5.92 to 15.78 cm/s with a mean of 8.61 ± 2.03 cm/s [Figure 4]. However, the mean RI of the study and control groups showed a statistically significant difference (P = 0.001) [Table 3]. The RI of the control group ranged from 0.67 to 0.88 with a mean of 0.77 ± 0.05, while the RI of the study group ranged from 0.37 to 0.89 with a mean of 0.69 [Figure 5]. There was also a statistically significant difference between the mean PI of the study and control groups (P = 0.001) [Table 3]. The PI of the study group ranged from 1.02 to 2.08 with a mean of 1.49 ± 0.26, while the PI of the study group ranged from 0.50 to 2.34 with a mean of 1.34 ± 0.44 [Figure 5]. | Table 3: Mean values of Doppler velocimetric indices of control and hypertensive subjects
Click here to view |
 | Figure 4: Histogram showing mean peak systolic velocity and end-diastolic velocity among hypertensive and control groups
Click here to view |
 | Figure 5: Histogram showing mean pulsatility index, RI, and systolic/diastolic ratio among hypertensive and controls
Click here to view |
There was a statistically significant difference between the mean S/D ratio of the study and control groups (P = 0.003) [Table 3]. The S/D ratio of the study group ranged from 1.58 to 8.17 with a mean of 3.64 ± 1.36, while the S/D ratio of the control group ranged from 3.00 to 8.43 with a mean of 4.53 ± 1.07 [Figure 5]. Majority of the patients in the study group had normal PSV (84.6%), while 15.4% had decreased PSV. The EDV was normal in 49.2% of the patients in the study group, 49.2% showed decreased EDV, and 1.5% had increased EDV. RI was normal in 69.2% of the patients in the study group, 27.7% showed decreased RI, while 3.1% showed higher RI values. PI was normal in majority of the patients in the study group (49.2%), while 46.2% showed decreased PI and 4.6% had higher PI. Majority of the patients (55.4%) in the study group showed decreased S/D ratio, while 43.1% had normal S/D ratio and 1.5% showed higher S/D ratio [Table 4]. | Table 4: Correlation of Doppler indices with gestational age among control group
Click here to view |
PSV showed a negative correlation with systolic BP among fetuses of hypertensive patients (P = −0.067). However, the correlation was not statistically significant (P = 0.597). There was a statistically significant correlation between the EDV and systolic BP among hypertensives (P = 0.299, r = 0.016). PI and S/D ratio also showed a negative correlation with systolic BP among hypertensives (r = −0.227 and − 0.209, respectively). However, the correlation was not statistically significant (P = 0.069 and 0.095, respectively). RI also showed a negative correlation with systolic BP, and the correlation was statistically significant (r = −0.314, P = 0.011) [Table 5]. In patients with severe hypertension with systolic BP ≥160 mmHg, EDV, RI, PI, and S/D ratio showed a statistically significant correlation with systolic BP (P = 0.008, 0.001, 0.050, and 0.025, respectively) [Table 6]. | Table 6: Regression statistics of indices with systolic blood pressure among hypertensives
Click here to view |
Only RI showed a negative correlation with diastolic BP among fetuses of hypertensive patients that was statistically significant (r = −0.283, P = 0.002) [Table 5]. Although PSV, PI, and S/D ratio showed a negative correlation with diastolic BP, they were not statistically significant (r = −0235, P = 0.06; r = −0124, P = 0.326; and r = −0.206, P = 0.99, respectively) [Table 7]. However, at diastolic BP ≥100 mmHg, RI, PI, and S/D showed a correlation that was statistically significant (r = −0.431, P = 0.02; r = −0.402, P = 0.03; and r = −0.380, P = 0.04, respectively) [Table 8]. | Table 7: Regression statistics of indices with diastolic blood pressure among hypertensives
Click here to view |
 | Table 8: Regression statistics of indices with systolic blood pressure ≥160
Click here to view |
| Discussion | | |
The mean age of the subjects in the study group was 31.5 ± 5.1 years which was similar to 31.33 ± 5.92 years reported by Ayyuba et al.[15] in Kano and 29.9 ± 6.4 years reported by Ye et al.[16] in China. However, the finding is slightly higher than 27 ± 6.0 years reported by Al-Ghamdi Saeed et al.[17] in Saudi Arabia. The variation in mean age of the study group with the one reported by Al-Ghamdi Saeed et al.[17] could be attributed to the difference in age at marriage and urbanization between Kano and North Western Province of Saudi Arabia. The mean age at first marriage of women in semi-urban and rural centers of Saudi area was 16 years,[18] while the mean age at first marriage for urban centers of Nigeria was 20.8 years. The mean age of the control group was 27.8 ± 4.4 years. Even though there was a difference between the mean age of the study and control groups, it was not statistically significant (P = 0.156). This is similar to the findings of Ali et al.[19] in Khartoum.
The mean parity of the study group was 4.1 ± 2.7. This finding is similar to the findings of Al Ghamdi Saeed et al.[17] in Saudi Arabia who recorded a mean parity of 4.9 ± 3.9. However, the finding is higher than that of Ali et al.[19] in Sudan who recorded a mean parity of 2.7 ± 1.7. The difference in parity between this study and that of Kassala, Sudan, could be attributed to the fact that Kassala is a rural area with many of the patients nulliparous and not educated up to the secondary school level.[19] Singh et al.,[20] in Sokoto, found a higher prevalence of hypertensive disorders in nulliparous and grand multiparous women. The higher parity recorded in this study could also be attributed to higher number of grand multiparous women in the study who have a greater risk for medical disorders such as essential hypertension. The mean parity of the control group was 2.8 ± 2.0. There was a statistically significant difference between the mean parity of the study and control groups (P = 0.002). This is similar to the findings of Ye et al.[16] in China who found a statistically significant difference between the parity of the hypertensive and normotensive patients.
The mean systolic BP of the study group was 157 ± 13.8 mmHg which is comparable to 158 ± 19.3 mmHg found by Koofreh et al.[21] in their study on preeclamptic patients in Calabar, Nigeria, and slightly higher than the findings of Al-Ghamdi Saeed et al.[17] in Saudi Arabia who found a mean systolic BP of 142 mmHg. There is a statistically significant difference between the mean systolic BP of the study and control groups (P = 0.004). The mean diastolic BP of the study group was 96 ± 11 mmHg which was similar to 98 ± 8 mmHg found by Al-Ghamdi Saeed et al.[17] in Saudi Arabia and 101.7 mmHg found by Koofreh et al.[21] in Calabar. There is a statistically significant difference between the mean diastolic BP of the study and control groups (P < 0.001).
The mean EFW of the study group was 2.10 ± 0.9 kg and 2.12 ± 1.0 kg for the control group. There is no statistically significant difference between the mean EFW between the study and control groups (P = 0.125). This is similar to the findings of Ayyuba et al.[15] in Kano who found no statistically significant difference between the EFW of babies of mothers with hypertensive disorders of pregnancy and normotensive mothers (P = 0.648). Similar finding was recorded by Singh et al.[20] in Sokoto who found no statistically significant difference between EFW of babies whose mothers have pregnancy-induced hypertension and those of normotensive mothers (P = 0.07).
There is a statistically significant difference between the mean AFI of the study and control groups (P = 0.002). The mean AFI of the study group was 13.8 ± 2.7 and 14.9 ± 1.9 for the control group. This is similar to the findings of Messawa et al.,[22] who found a statistically significant difference between the mean AFI of normal pregnant women and those with hypertensive disorders of pregnancy in their study on the Doppler ultrasound in high-risk pregnancies in Makkah, Saudi Arabia (P ≤ 0.001). The similarity between the findings of this study and that of Messawa et al.[22] could be attributed to the relative placental insufficiency that occurs in hypertensive disorders of pregnancy. Amniotic fluid is partly produced by the placenta and other sources like the urine produced by the fetus. Decreased placental blood flow and ischemia that occur in patients with hypertensive disorders of pregnancy cause a reduction in amniotic fluid volume.
This study found that PSV increased with increase in gestational age in normotensive pregnant women. This is similar to the findings of Tarzanmi et al.[8] in Iran that showed an increase of PSV with increasing gestational age. Similar findings were documented by Ehigiamusoe et al.[23] in Benin City and Taher et al.[24] in Bangladesh. Furthermore, this study found a positive linear relationship between PSV and gestational age (r = 0.400, P = 0.001). This finding was similar to that of Seffah et al.[25] in Ghana. This finding of increase in PSV with advancing gestational age consistent with other studies is attributed to the progressive increase in fetal cardiac output as the pregnancy advances to compensate for increased fetal demand of oxygen and nutrients.
Similarly, this study found an increase in EDV with advancing gestational age. This is similar to the findings of Ehigiamusoe et al.[23] in Benin. This finding of increase in EDV with advancing gestational age is attributed to the decrease in vascular resistance of the fetal MCA with advancing gestational age.
RI was found to decrease with increasing gestational age. This was similar to the findings of Ehigiamusoe et al.,[23] Taher et al.,[24] and Seffah et al.[25] There was a negative linear correlation between the RI and gestational age (r = −0.038, P = 0.764), but the relationship was not statistically significant. The finding was, however, slightly different from that of Tarzanmi et al.,[8] who found a significant relationship between RI and increasing gestational age. This could be attributed to the marked difference in sample size between this study and that of Tarzanmi et al.,[8] who conducted their study on 1037 patients.
PI also showed a decrease with increasing gestational age. This is similar to the findings of Tarzanmi et al.,[8] Ehigiamusoe et al.,[23] Taher et al.,[24] and Seffah et al.[25] PI showed a significant negative relationship with increasing gestational age (r = −0.063, P = 0.026). This is similar to the findings of Tarzanmi et al.[8] The reduction in PI with advanced gestational age is attributed to decrease in fetal MCA vascular resistance as the pregnancy advances.
Similarly, the S/D ratio was found to decrease with increasing gestational age. This was similar to the findings of other workers. There was no statistically significant correlation between the S/D ratio and increasing gestational age (r = −0.063, P = 0.619). This was similar to the finding of Taher et al.,[24] but different from the finding of Tarzanmi et al.,[8] who found a statistically significant correlation between decrease in S/D ratio and increasing gestational age. This could be attributed to the difference between the sample size of this study and that of Tarzanmi et al.,[8] whose sample size was significantly larger.
This study found a spectrum of abnormalities of MCA Doppler indices in patients with hypertensive disorder of pregnancy. Only 15.4% of the patients in this study showed an abnormal decrease in PSV. This is significantly lower than 76% of abnormalities of MCA PSV found by Yakasai et al.[26] in their study of the pattern of arterial blood flow in some selected vessels in patients with pregnancy-induced hypertension in Kano, Nigeria. This could be accounted for by the difference in sample size between this study and that of Yakasai et al.,[26] who conducted their study in 34 patients as against 65 in this study. Moreover, Yakasai et al.[26] conducted their study in patients with pregnancy-induced hypertension alone excluding other forms of hypertensive disorders of pregnancy. Patients in the study group showed a decrease in fetal MCA PSV when compared with the control group with a mean PSV of 32.1 ± 10 cm/s and 38.4 ± 9.2 cm/s, respectively. This is similar to the findings of Yakasai et al.,[26] who found lower mean fetal MCA PSV in patients with pregnancy-induced hypertension when compared with normotensive patients. There was no statistically significant correlation between the fetal MCA PSV with both maternal systolic and diastolic BP (P = 0.597 and 0.06, respectively). Even in patients with severe systolic hypertension with BP ≥160 mmHg, and diastolic BP ≥100 mmHg, there was no statistically significant correlation between fetal MCA PSV with maternal systolic and diastolic BP (P = 0.781 and 0.301, respectively).
The patients in the study group showed higher EDV values when compared with normotensive patients with a mean EDV of 9.1 ± 2.9 cm/s and 8.61 cm/s, respectively, even though the difference was not statistically significant. This is similar to the findings of Bhatt et al.[27] in India who found higher EDV in fetuses of mothers with pregnancy-induced hypertension due to brain sparing action. EDV showed a significant correlation with systolic BP among hypertensives (P = 0.016). However, the correlation with diastolic BP was not statistically significant (P = 0.704). In patients with severe systolic hypertension, and diastolic BP ≥160 mmHg, there was also a statistically significant correlation with systolic BP (P = 0.008) and no statistically significant correlation was seen with diastolic BP (P = 0.257).
RI was abnormal in 30.8% of the patients in the study group. This was lower than 58% found by Yakasai et al.[26] The lower findings recorded by this study could be attributed to lower sample size of the study by Yakasai et al.,[26] and conduct of their study in patients with pregnancy-induced hypertension alone excluding other forms of hypertension. Mean RI was lower in patients with hypertensive disorders in pregnancy when compared to normotensive patients with a mean of 0.70 and 0.77, respectively. The difference in mean RI between hypertensive and normotensive patients was statistically significant (P < 0.001). This is similar to the findings of Gupta et al.,[28] and Khalid et al.,[29] who found a statistically significant reduction in mean RI in patients with pregnancy-induced hypertension. RI showed a significant correlation with systolic and diastolic BP (P = 0.011 and 0.023, respectively). In patients with severe systolic hypertension; and diastolic BP ≥ 100 mmHg, RI also showed a statistically significant correlation with both systolic and diastolic BP (P = 0.01 and 0.02, respectively).
The patients in the study group also showed lower PI when compared with the patients in the control group with a mean of 1.35 and 1.49, respectively. The difference in mean PI between the study and control groups was statistically significant (P < 0.001). This is similar to the findings of Gupta et al.,[28] and Khalid et al.[29] PI did not show a statistically significant correlation with systolic and diastolic BP among the hypertensive group (P = 0.069 and 0.326), respectively. However, in patients with severe systolic hypertension; and diastolic BP ≥ 160 mmHg, there was a statistically significant correlation of PI with diastolic and systolic BP (P = 0.05 and 0.03, respectively).
Among hypertensive patients, 56.9% showed abnormal S/D ratio which was lower than the 88% recorded by Yakasai et al.[26] This could be attributed to the lower sample size of Yakasai et al.,[26] and selection of patients with pregnancy-induced hypertension alone excluding other forms of hypertensive disorders of pregnancy. There was also lower S/D ratio among hypertensive patients when compared with normotensives with a mean of 3.64 and 4.53, respectively. The difference in mean S/D ratio between the study and control groups was statistically significant (P = 0.03). This was similar to the findings of Gupta et al.,[28] and Khalid et al.[29] The S/D ratio did not show a statistically significant correlation with systolic and diastolic BP among hypertensive patients (P = 0.095 and 0.099, respectively). However, in patients with severe systolic hypertension; and diastolic BP ≥100 mmHg, there was a statistically significant correlation with systolic and diastolic BP (P = 0.025 and 0.042, respectively).
The general pattern of abnormalities of fetal MCA Doppler indices in patients with hypertensive disorders of pregnancy is a statistically significant decrease in PSV, RI, PI, and S/D ratio, while the EDV increases. Similarly, there was a statistically significant correlation between maternal increase in systolic and diastolic BP, and abnormalities of Doppler indices.
Fetal MCA demonstrates high resistant waveforms (high systolic velocity and low or absent diastolic velocity) throughout pregnancy. The mean values of indices (PI, RI, and S/D ratio) showed decline with increasing gestational age due to decreased resistance of the vessel to meet the oxygen demand of the growing fetus, while PSV and EDV increase with advancing gestational age. In hypertensive disorders of pregnancy, due to chronic hypoxia, there is redistribution of blood flow to the essential organs such as the heart and the myocardium.[29],[30] This study found a significant reduction of fetal MCA Doppler indices (PSV, RI, PI, and S/D ratio) in patients with hypertension disorders of pregnancy similar to other studies,[26],[29] while the fetal MCA EDV increases due to cerebral redistribution of blood.
The study also found a statistically significant relationship between increase in BP and abnormalities of fetal MCA Doppler indices.
| Conclusion | | |
The usefuleness of assessment of fetal MCA Doppler velocimetry in patients with hypertensive disorders of pregnancy has been shown by this study vis;Featuses of patients with hypertensive disorders of pregnancy show brain sparing effect to allow redistribution of blood to cerebral circulation.This manifest as statistically significant decrease in Fetal MCA,RI,PI and SD ratio; and increase in fetal MCA EDV.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Dolea C, Abou Zahr C. Global Burden of Hypertensive Disorders of Pregnancy in the Year 2000, Evidence and Information for Policy. Geneva: World Health Organization Report; 2003.  |
| 2. | Nwabueze PO, Okwuoma CA, Nwankwo BO, Nwabueze AE. Occurrence of pregnancy induced hypertension in selected health facilities in South Eastern Nigeria. Int J Trop Med 2012;7:86-92. |
| 3. | Agwu UM, Ifebunandu N, Obuna JA, Nworie CE, Nwokpo OS, Umeora OU. Prevalence of medical disorders in pregnancy in Ebonyi State University. J Basic Clin Reprod Sci 2013;2:22-6. [Full text] |
| 4. | National High Blood Pressure Education Program Working Group Report on High Blood. Pressure in pregnancy. Am J Obstet Gynecol 1990;163:689-712. |
| 5. | Jido TA, Yakasai, IA. Pre-eclampsia a review of the evidence. Ann Afr Med 2013;12:75-8. [ PUBMED] [Full text] |
| 6. | Yelikar KA, Prabhu A, Thakre GG. Role of fetal Doppler and non-stress test in preeclampsia and intrauterine growth restriction. J Obstet Gynaecol India 2013;63:168-72. |
| 7. | Shahinaj R, Manoku N, Kroi E, Tasha I. The value of the middle cerebral to umbilical artery Doppler ratio in the prediction of neonatal outcome in patient with preeclampsia and gestational hypertension. J Prenat Med 2010;4:17-21. |
| 8. | Tarzamni MK, Nezami N, Gatreh-Samani F, Vahedinia S, Tarzamni M. Doppler waveform indices of fetal middle cerebral artery in normal 20 to 40 weeks pregnancies. Arch Iran Med 2009;12:29-34. |
| 9. | Duley L. Pre-eclampsia and the hypertensive disorders of pregnancy. Br Med Bull 2003;67:161-76. |
| 10. | |
| 11. | Paudel S, Lohani B, Gurung G, Ansari MA, Kayastha P. Reference values for Doppler indices of the umbilical and fetal middle cerebral arteries in uncomplicated third trimester pregnancy. J Inst Med 2010;32:5-13. |
| 12. | Miguil M, Salmi S, Moussaid I, Benyounes R. Acute renal failure requiring haemodialysis in obstetrics. Nephrol Ther 2011;7:178-81. |
| 13. | |
| 14. | |
| 15. | Ayyuba R, Abubakar IS, Yakasai, IA. Umblical artery Doppler velocimetry study in prediction of adverse pregnancy outcomes among pregnant women with hypertensive disorders of pregnancy in Kano Nigeria. Niger J Basic Clin Sci 2015;12:95-104. [Full text] |
| 16. | Ye C, Ruan Y, Zou L, Li G, Li C, Chen Y, et al. The 2011 survey on hypertensive disorders of pregnancy (HDP) in China: Prevalence, risk factors, complications, pregnancy and perinatal outcomes. PLoS One 2014;9:e100180. |
| 17. | Al-Ghamdi Saeed MG, Al-Harbi AS, Khalil A, El-Yahyia A. Hypertensive disorders of pregnancy: Prevalence, classification and adverse outcomes in Northwestern Saudi Arabia. Ann Saudi Med 1999;19:557-560. |
| 18. | Faraq MK, Al Mazrou YY, Baido MH, Aziz KM, Al-Shehri SN. Nuptiality pattern in Saudi Arabia. J Trop Pediatr 1995;41 Suppl 1:8-20. |
| 19. | Ali AA, Rayis DA, Abdallah TM, Abdullahi H, Adam I. Hypertensive disorders of pregnancy in Kassala Hospital, Eastern Sudan. Khartoum Med J 2011;4:656-9. |
| 20. | Singh S, Ekele B, Shehu C, Nwobodo E. The prevalence and outcome of hypertensive disorders in pregnancy in Usmanu Danfodio University Teaching Hospital, Sokoto Nigeria. Niger Med J 2014;55:384-8. [ PUBMED] [Full text] |
| 21. | Koofreh ME, Ekott ME, Kpoudom DO. The prevalence of pre-eclampsia among pregnant women in University of Calabar Teaching Hospital, Calabar. Saudi J Health Sci 2014;3:133-6. |
| 22. | Messawa M, Ma'ajeni E, Daghistani MH, Ayaz A, Farooq MU. The role of Doppler ultrasound in high risk pregnancies: A comparative study. Niger Med J 2012;53:116-20. [ PUBMED] [Full text] |
| 23. | Ehigiamusoe FO, Igbinedion BO. Normal middle cerebral arteries doppler velocimerty; a study from Benin city. Niger J Hosp Pract 2014;14:3-6. |
| 24. | Taher MA, Tasnim NB, Mohiuddin AS, Alam MM, Sharif MM, Mannan AD, et al. Doppler flow velocity indices (RI, PI, S/D & PSV) of fetal middle cerebral artery in normal pregnancies: Correlation with gestational age of 20 to 40 weeks. Birdem Med J 2012;2:77-8. |
| 25. | Seffah JD, Swarray-Deen A. Fetal middle cerebral artery Doppler indices and clinical application at Korle Bu Teaching Hospital, Accra, Ghana. Int J Gynaecol Obstet 2016;134:135-9. |
| 26. | Yakasai IA, Tabari MA, Rabiu A, Ismail A. Pattern of fetal arterial blood flow in selected vessels in patients with pregnancy induced hypertension in Aminu Kano Teaching Hospital Kano, Nigeria. West Afr J Radiol 2013;20:9-13. [Full text] |
| 27. | Bhatt CJ, Arora J, Shah MS. Role of colour Doppler in pregnancy. Indian J Radiol Imaging 2013;13:417-20. |
| 28. | Gupta S, Misra R, Ghosh UK, Gupta V, Srivastava D. Comparison of foeto-maternal circulation in normal pregnancies and pregnancy induced hypertension using color Doppler studies. Indian J Physiol Pharmacol 2014;58:282-7. |
| 29. | Khalid M, Wahab S, Kumar V, Khalid S, Haroon S, Sabzposh NA. Doppler indices in prediction of fetal outcome in hypertensive pregnant women. Nepal J Obstet Gynaecol 2011;6:28-34. |
| 30. | Fatemah RS, Fatemeh M, Reihaneh P, Nastara T, Mamak S, Zahra F. Comparison of fetal middle cerebral artery colour Doppler ultrasound for predicting neonatal outcome in complicated pregnancies with fetal growth restriction. Vietnam J Biomed 2018;5:2296-304. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]
|
Search Pubmed for