Background
Umbilical artery absent end-diastolic velocity indicates increased placental resistance
and is associated with increased risk of perinatal demise and neonatal morbidity in
fetal growth restriction. However, the clinical implications of intermittent vs persistent
absent end-diastolic velocity are unclear.
Objective
We compared umbilical artery Doppler velocimetry changes during pregnancy and neonatal
outcomes between pregnancies with fetal growth restriction and intermittent absent
end-diastolic velocity and those with persistent absent end-diastolic velocity.
Study Design
In this retrospective study of singletons with fetal growth restriction and absent
end-diastolic velocity, umbilical artery Doppler abnormalities were classified as
follows: intermittent absent end-diastolic velocity (<50% of cardiac cycles with absent
end-diastolic velocity) and persistent absent end-diastolic velocity (≥50% of cardiac
cycles with absent end-diastolic velocity). The primary outcome was umbilical artery
Doppler progression to reversed end-diastolic velocity. Secondary outcomes included
sustained umbilical artery Doppler improvement, latency to delivery, gestational age
at delivery, neonatal morbidity composite, rates of neonatal intensive care unit admission,
and length of neonatal intensive care unit stay. Outcomes were compared between intermittent
absent end-diastolic velocity and persistent absent end-diastolic velocity. Multivariate
logistic regression was used to adjust for confounders. A receiver operating characteristic
curve was generated to assess the sensitivity and specificity of the percentage of
waveforms with absent end-diastolic velocity in predicting the neonatal composite.
The Youden index was used to calculate the optimal absent end-diastolic velocity percentage
cut-point for predicting the neonatal composite.
Results
Of the 77 patients included, 38 had intermittent absent end-diastolic velocity and
39 had persistent absent end-diastolic velocity. Maternal characteristics, including
age, parity, and preexisting conditions did not differ significantly between the 2
groups. Progression to reversed end-diastolic velocity was less common in intermittent
absent end-diastolic velocity than in persistent absent end-diastolic velocity (7.9%
vs 25.6%; odds ratio, 0.25; 95% confidence interval, 0.06–0.99). Sustained umbilical
artery Doppler improvement was more common in intermittent absent end-diastolic velocity
than in persistent absent end-diastolic velocity (50.0% vs 10.3%; odds ratio, 8.75;
95% confidence interval, 2.60–29.5). Pregnancies with intermittent absent end-diastolic
velocity had longer latency to delivery than those with persistent absent end-diastolic
velocity (11 vs 3 days; P<.01), and later gestational age at delivery (33.9 vs 28.7 weeks; P<.01). Composite neonatal morbidity was less common in the intermittent absent end-diastolic
velocity group (55.3% vs 92.3%; P<.01). Neonatal death occurred in 7.9% of intermittent absent end-diastolic velocity
cases and 33.3% of persistent absent end-diastolic velocity cases (P<.01). The differences in neonatal outcomes were no longer significant when controlling
for gestational age at delivery. The percentage of cardiac cycles with absent end-diastolic
velocity was a modest predictor of neonatal morbidity, with an area under the receiver
operating characteristic curve of 0.71 (95% confidence interval, 0.58–0.84). The optimal
percentage cut-point for fetal cardiac cycles with absent end-diastolic velocity observed
at the sentinel ultrasound for predicting neonatal morbidity was calculated to be
47.7%, with a sensitivity of 65% and specificity of 85%.
Conclusions
Compared with persistent absent end-diastolic velocity, diagnosis of intermittent
absent end-diastolic velocity in the setting of fetal growth restriction is associated
with lower rates of progression to reversed end-diastolic velocity, higher likelihood
of umbilical artery Doppler improvement, longer latency to delivery, and higher gestational
age at delivery, leading to lower rates of neonatal morbidity and death. Our data
support using an absent end-diastolic velocity percentage cut-point in 50% of cardiac
cycles to differentiate intermittent absent end-diastolic velocity from persistent
absent end-diastolic velocity. This differentiation in growth-restricted fetuses with
absent end-diastolic velocity may allow further risk stratification.
Key words
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Article Info
Publication History
Published online: June 09, 2022
Accepted:
June 3,
2022
Received in revised form:
May 29,
2022
Received:
March 1,
2022
Publication stage
In Press Journal Pre-ProofFootnotes
The authors report no conflict of interest.
Cite this article as: Bligard KH, Xu X, Raghuraman N, et al. Clinical significance of umbilical artery intermittent vs persistent absent end-diastolic velocity in growth-restricted fetuses. Am J Obstet Gynecol 2022;XX:x.ex–x.ex.
Identification
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