Absent end diastolic flow - umbilical artery

Case contributed by Dennis Odhiambo Agolah
Diagnosis certain


Patient with severe pre-eclampsia. Now twenty eight weeks by last normal monthly period.

Patient Data

Age: 30 years
Gender: Female

There is a single viable intrauterine pregnancy in cephalic presentation with normal myocardial, somatic activity, and gross fetal morphology. The liquor is adequate for gestation. The placental plate is fundal-anterior with no detachment from the uterine wall, however, with small multiple infarcts within its substance (approximately 5-10 %). The cervix is closed and measures 3.4 cm in length.

Fetal Doppler velocimetry shows absent end diastolic flow within the fetal umbilical artery more towards the middle and the proximal fetal end with resultant elevated resistive index (>1) along the mentioned portions. Ductus venosus, right middle cerebral artery, and the maternal right uterine artery waveforms, resistive and pulsatility indices are normal. The left maternal uterine artery waveform exhibits persistent early dicrotic notch with a mildly elevated pulsatility index measuring 1.42 however with a normal ipsilateral resistive index of 0.69.

Case Discussion

Elevated umbilical arterial resistive index due to absent end diastolic flow within the umbilical artery waveform is likely attributable to early placental insufficiency/ arterial resistance at the placental bed. Small multiple placental infarcts are noted.

The left maternal uterine arterial waveform exhibits a dicrotic notch with a mildly elevated pulsatility index consistent with the pre-eclamptic state. No gross features of intrauterine growth restriction as yet as the composite gestational age by ultrasound corresponding to twenty-six weeks noted, shows no significant discordance with the tabulated maternal last monthly period dating which yields twenty-eight weeks. The biophysical profile score favorably is 8/8 however, the cerebral-placental ratio is less than 1 (0.88) owing to the paradoxical higher umbilical arterial resistive index.

On a follow-up, (after two days post scanning), the fetus was delivered as a still birth.

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