Book Reading

Fetomaternal

Noninvasive Detection of Fetal

Anemia by Doppler Ultrasonogtaphy

Presented by Dr. Aswin Boy Pratama

Moderator:
Dr. H. Wim T. Pangemanan, SpOG(K)
Ultrasonographic Evaluation of Fetal Anemia

Evaluation fetal hydrops serial ultrasound with Hb levels <

5gxdL-1
Combined Doppler measurements of fetal aorta, inferior vena
cava, and umbilical vein predict fetal anemia
Middle cerebral artery peak systolic velocity Doppler
measurements accurately predict fetal anemia
 Evidence Supporting

1995, Mari et al. MCA - peak systolic velocity Doppler

measurements accurately predict fetal anemia in a prospevtive series
of 16 pregnancies
2000, larger multicentered study from 111 fetuses at risk for
anemia reported 23 fetuses had moderate to severe anemia and all
of fetuses were above 1,5 MoM
Zimmermann et al. 2002 peak systolic velocity Doppler over 1,5
MoM sensitivity 88% and specificity 87%
Table 49.1 Middle Cerebral Artery Peak Systolic Velocity as
Table 49.2 Fetal Hb as a funcyion of gestational age
a funcyion of gestational age

Weeks of MCA PSV (multiple of the median) Weeks of Fetal Hb (multiple of the median)
gestation gestation
1.00 cm x 1.29 cm x 1.50 cm x 1.55 cm x 1.16 g x 1.00 g x 0.84 g x 0.65 g x 0.55 g x
sec-1 sec-1 sec-1 sec-1 dL-1 dL-1 dL-1 dL-1 dL-1
18 23.2 29.9 34.8 36.6 18 12.3 10.6 8.9 6.9 5.8
20 25.5 32.8 38.2 39.5 20 12.9 11.1 9.3 7.2 6.1
22 27.9 36.0 41.9 43.3 22 13.4 11.6 9.7 7.5 6.4
24 30.7 39.5 46.0 47.5 24 13.9 12.0 10.1 7.8 6.6
26 33.6 43.3 50.4 52.1 26 14.3 12.3 10.3 8.0 6.8
28 36.9 47.6 55.4 57.2 28 14.6 12.6 10.6 8.2 6.9
30 40.5 52.2 60.7 62.8 30 14.8 12.8 10.8 8.3 7.1
32 44.4 57.3 66.6 68.9 32 15.2 13.1 10.9 8.5 7.2
34 48.7 62.9 73.1 75.6 34 15.4 13.3 11.2 8.6 7.3
36 53.5 69.0 80.2 82.9 36 15.6 13.5 11.3 8.7 7.4
38 58.7 75.7 88.0 91.0 38 15.8 13.6 11.4 8.9 7.5
40 64.4 83.0 96.6 99.8 40 16.0 13.8 11.6 9.0 7.6
Technique for Measuring the Middle Cerebral
Artery Peak Systolic Velocity

Identification of midbrain structures (thallami and cavum septum

pellucidum) move tranducer in a slight caudal direction
identify the circle Willis bilateral middle cerebral arteries
should be visualized
The peak systolic velocity should be measured in the proximal
middle cerebral artery 2mm after its origin from the internal
carotid artery.
Fig 49.1 Doppler assessment of the Fetal Middle Cerebral Artery

Fig. 49.1
Management with Middle Cerebral Artery Peak
Systolic Velocity Compared to Conventional
Management with Amniocentesis AOD
Its better in predictive value for moderate to severe anemia in red cell
alloimmunization than conventional management
91% of sensitivity and 100% of specificity
The main benefit to management with middle cerebral artery peak systolic
velocity Doppler is a reduction in invasive procedures and avoidance of
potential complications
Limitation of Middle Cerebral Artery Peak
Systolic Velocity
Its appears to diminish after 35 weeks of gestation, leading to higher false
positive rates for prediction of anemia
Multiple intrauterine transfusion increase fetal blood viscosity which may
alter the predictive accuracy of middle cerebral artery peak systolic velocity
Doppler
The result not affected by the presence of congenital heart disease
In case of fetal hydrops may be diminished by compromised cardiac output
Potential Pitfalls in Measuring Middle Cerebral
Artery Peak Systolic Velocity
Measurements taken in the distal middle cerebral artery or with an angle of
insonation above 200 may underestimate the peak systolic velocity and
decrease sensitivity
Its influence by multiple factors such as variation fetal heart rate, both
bradycardia and tachycardia, fetal behavior state and activity level measure
during periods of fetal apnea and when fetal activity is minimal
The reliability of middle cerebral artery peak systolic velocity to detect
anemia during active labor has been not established
Algorithm for Fetal Surveillance Using Middle
Cerebral Artery Peak Systolic Velocity
Areas for Future Research with Middle Cerebral
Peak Systolic Velocity

Predict anemia in fetus with:

genetic syndrome (thrombositopenia absent radius, Fanconi syndrome)
hemoglobinopathies (alpha-thalassemia), or
viral infection (can cause myocarditis)
Suspected Fetal Haemorrhage

The diagnose of fetomaternal haemorrhage is typically made by

demonstration of fetal erythrocytes in maternal circulation by Kleihauer-
Betke acid-elution stain
Conclusion
The accuracy of middle cerebral artery peak systolic velocity Doppler has
been established for the prediction of fetal anemia in cases of red cell
alloimmunization
Simultaneous management by conventional amniocentesis AOD needed in
case which middle cerebral peak systolic velocity Dopples has not been
established