Doppler Ultrasound in Obstetrics and Gynecology

Description

Expanded and updated edition highlighting current standards and breakthroughs in the technology of Doppler ultrasound Includes latest advances in 3D and color doppler and 4D fetal echocardiography Includes more than 500 illustrations, including more than 150 in color Preface Contents 1: Doppler Sonography: A Brief History 1.1 Introduction 1.2 Christian Andreas Doppler and the Doppler Theory 1.2.1 Early Life 1.2.2 The Doppler Theory 1.2.3 Verification of Doppler’s Theory 1.2.4 Later Life 1.3 Early Application of Doppler Theory 1.4 Development of Spectral Doppler Ultrasonography 1.5 Development of Color Doppler Ultrasonography 1.6 Development of Doppler Sonography in Obstetrics 1.6.1 Early Work 1.6.2 Doppler Ultrasound of the Umbilical Artery 1.6.3 Doppler Ultrasound of the Fetal Venous Circulation 1.6.4 Doppler Ultrasound of the Fetal Cerebral Circulation 1.6.5 Doppler Ultrasound of the Miscellaneous Fetal Arterial Circulation 1.6.6 Doppler Ultrasound of the Uteroplacental Circulation 1.6.7 Fetal Doppler Echocardiography 1.6.8 Promotion of Fetal Doppler 1.7 Doppler Application in Gynecology References 2: Physical Principles of Doppler Ultrasonography 2.1 Propagation of Sound 2.2 Propagation Speed of Sound 2.3 Wavelength, Frequency, Pulse 2.4 Amplitude, Power, Intensity 2.5 Ultrasound and Piezoelectric Effect 2.6 Characteristics of Sound Transmission in a Medium 2.7 Doppler Effect 2.8 Doppler Ultrasound 2.9 Backscattering 2.10 Magnitude of Doppler Shift 2.11 Angle Dependence of Doppler Shift References 3: Spectral Doppler: Basic Principles and Instrumentation 3.1 Doppler Signal Processing 3.2 Reception-Amplification 3.3 Demodulation 3.4 Direction Discrimination 3.5 High-Pass and Low-Pass Filters 3.6 Doppler Spectral Analysis 3.7 Fourier Transform Spectral Analysis 3.8 Limitations of FFT Spectral Analysis 3.8.1 Spectral Variance 3.8.2 Intrinsic Spectral Broadening 3.9 Analog Fourier Spectral Analysis 3.10 Autoregression Analysis 3.11 Continuous-Wave Doppler Ultrasonography 3.12 Pulsed-Wave Doppler Ultrasonography 3.13 Doppler Sample Volume 3.14 Artifacts of Spectral Doppler Sonography 3.15 Nyquist Limit 3.16 Implications of Aliasing 3.17 Range-Velocity Resolution 3.18 Mirror Imaging 3.19 Duplex System 3.19.1 Principles of the Duplex Doppler System 3.19.2 Optimal Configuration of a Duplex System: Imaging Versus Doppler System 3.19.3 Duplex Implementation 3.19.4 Electronic Array Scanner 3.20 Integration of the Doppler and Imaging Functions in Array Transducer 3.21 Doppler Display References 4: Spectral Doppler Sonography: Waveform Analysis and Hemodynamic Interpretation 4.1 Spectral Doppler Sonogram 4.2 Doppler Frequency Shift Envelopes 4.2.1 Maximum Frequency Shift Envelope 4.2.2 Mean Frequency Shift Envelope 4.2.3 First Moment Envelope 4.3 Hemodynamic Information from Doppler Sonography 4.3.1 Flow Detection 4.3.2 Flow Direction 4.3.3 Flow Velocity Profile 4.3.4 Doppler Flow Quantification 4.4 Principle of Doppler Flowmetry 4.5 Doppler Velocity Measurement 4.5.1 Uniform Insonation Method 4.5.2 Assumed Velocity Profile Method 4.6 Determination of Vascular Luminal Area 4.7 Determination of the Angle of Insonation 4.8 Alternative Methods of Doppler Flowmetry 4.9 Doppler Waveform Analysis and Doppler Indices 4.10 Comprehensive Waveform Analysis 4.11 Choice of Indices 4.12 Sources of Variance of the Doppler Indices 4.13 Hemodynamic Basis of Doppler Waveform Analysis 4.14 Experimental Approaches to Hemodynamic Validation of Doppler Indices 4.15 Arterial Input Impedance: Basic Concepts and Relevance to Doppler Waveform Analysis 4.16 Doppler Indices and Peripheral Resistance 4.17 Doppler Indices and Input Impedance 4.18 Doppler Indices and Central Circulation 4.19 Placental Vascular Changes and Abnormal Doppler Waveforms References 5: Venous Hemodynamics 5.1 Blood Velocity in Veins 5.1.1 Laminar Flow, Turbulent Flow, or Whirls 5.1.2 Parabolic Flow and Other Velocity Profiles 5.2 Viscosity Effect on Venous Flow 5.3 Pressure Gradient and Resistance in Venous Flow 5.4 Measuring Blood Flow in Veins 5.4.1 Determining Blood Velocity 5.4.2 Determining Vessel Diameter 5.5 Pulsation in Veins 5.5.1 Transmission Lines 5.5.2 Wave Reflections 5.5.3 Direction of Pulse and Blood Velocity 5.5.4 Compliance and Reservoir Function of the Umbilical Vein 5.5.5 Source of Pulse 5.5.6 Cardiac Function and Waveform References 6: Doppler Color Flow: Basic Principles 6.1 Introduction 6.2 Principles of Doppler Color Flow Mapping 6.2.1 Multigated Doppler Interrogation 6.2.2 Color Doppler Signal Analysis 6.2.3 Instrumentation 6.2.4 Color Flow Processor 6.2.5 Transducers for Two-Dimensional Doppler Color Flow Mapping 6.2.6 Color Mapping 6.2.7 Color Classification 6.2.8 Color Perception 6.2.9 Color Encoding of Doppler Flow Signals 6.2.10 Color Mapping of Direction of Flow 6.2.11 Clinical Utility of Color Flow Mapping 6.2.12 Color Mapping of Variance 6.2.13 Formation of a Color Frame 6.2.14 Persistence 6.2.15 Frame Rate 6.2.16 M-Mode Color Frame Formation 6.3 Operational Considerations 6.3.1 Transducer Frequency 6.3.2 Pulse Repetition Frequency 6.3.3 Doppler Color Flow Gain 6.3.4 High-Pass Filter (Wall Filter, Clutter Filter) 6.4 Limitations of Color Doppler 6.4.1 Aliasing 6.4.2 Range Ambiguity 6.4.3 Temporal Ambiguity 6.4.4 Angle of Insonation 6.4.5 Wall Motion Ghost Signals 6.4.6 Mirroring 6.5 Color Flow Visualization 6.6 Power Doppler 6.6.1 Directional Power Doppler 6.6.2 Power Doppler Microvascular Flow Imaging 6.7 Four-Dimensional Doppler Color Flow Mapping References 7: Biosafety of Diagnostic Doppler Ultrasound 7.1 Introduction 7.2 Acoustic Output from Diagnostic Scanners 7.3 Safety Standards and Regulation 7.4 Thermal Index 7.5 Mechanical Index 7.6 What Can the Operator Do? 7.7 Evidence from Human Studies 7.8 Guidelines and Recommendations References 8: Fetal Cardiovascular Physiology 8.1 Fetal Oxygenation 8.2 Development of Fetal Basal Cardiovascular Function 8.3 Fetal Cardiovascular Function During Stress 8.4 Fetal Hypoxia 8.5 Fetal Cardiovascular Responses to Acute Hypoxia 8.6 Functional Importance of the Fetal Cardiovascular Responses to Acute Hypoxaemia 8.7 Physiology Underlying the Fetal Cardiovascular Responses to Acute Hypoxaemia 8.7.1 Afferent Neural Pathways 8.7.2 Efferent Neural Pathways 8.7.3 Endocrine Mechanisms 8.7.4 Local Mechanisms 8.8 Maturation of the Fetal Cardiovascular Responses to Acute Hypoxaemia 8.9 Modulation of Fetal Cardiovascular Function by Adverse Intrauterine Conditions References 9: Maternal Cardiovascular Physiology and Assessment 9.1 Introduction 9.2 Blood Pressure Regulation 9.3 Clinical Consequences of Circulatory Maladaptation to Pregnancy 9.4 Magnitude of Healthy Circulatory Changes 9.5 Assessment of Cardiac Output 9.6 Practical Assessment of Stroke Volume 9.7 Summary References 10: Venous Doppler Sonography in Pregnancy 10.1 Aspects of Venous Physiology 10.2 The Venous Doppler Waveform Explained 10.3 Technique of Intrahepatic and Intrarenal Venous Doppler Sonography 10.4 Methodologic Improvement of Venous Doppler Flow Imaging 10.5 Venous Doppler Flow Characteristics in Normal and Pathologic Pregnancies 10.5.1 Normal Pregnancy 10.5.2 Preeclampsia 10.5.3 Gestational and Essential Hypertension 10.5.4 Normotensive Pregnancies with Newborns Small for Gestational Age 10.6 Relevance of Maternal Venous Hemodynamics Assessment 10.6.1 Pathophysiology of Preeclampsia and Gestational Hypertension 10.6.2 Screening for Preeclampsia 10.6.3 Management 10.7 Pitfalls and Limitations of Maternal Venous Hemodynamics Assessment 10.8 Conclusion References 11: Relationship Between Maternal and Fetal Cardiovascular Function 11.1 Overview of Maternal Cardiovascular Function in Health and Disease 11.2 Uterine Artery Doppler, Trophoblast Invasion, and Maternal Cardiovascular Function 11.3 Maternal Cardiovascular Function and Fetal Doppler Indices: Umbilical Artery, Middle Cerebral Artery, and Ductus Venosus 11.4 Maternal Cardiovascular Function, Fetal Growth, and Birthweight References 12: Intrauterine Blood Flow and Postnatal Development 12.1 Background 12.1.1 Neurodevelopmental Outcome in FGR 12.1.2 FGR and Cardiovascular Morbidity 12.2 Postnatal Implications of Abnormal Fetal Blood Flow 12.2.1 Neonatal Outcome 12.3 Long-Term Neurodevelopmental Implications 12.3.1 Umbilical Artery Blood Flow 12.3.1.1 The Lund-Malmö Study Early-Onset FGR Cohort—Background Material Neurological and Cognitive Development 12.3.2 Fetal Cerebral Blood Flow 12.3.3 Fetal Aortic Blood Flow 12.3.3.1 The Lund-Malmö Study Late-Onset FGR Cohort—Background Material Neurological and Cognitive Development at 7 Years of Age Cognitive Outcome at 18 Years of Age Retinal Neural Morphology and Function 12.4 Postnatal Brain Morphology 12.5 Cardiovascular Morphology and Function 12.5.1 Umbilical Artery Blood Flow 12.5.1.1 The Lund-Malmö Study Early-Onset FGR Cohort 12.5.2 Fetal Aortic Blood Flow 12.5.2.1 The Lund-Malmö Study Late-Onset FGR Cohort 12.5.3 Fetal Cerebral Blood Flow 12.6 Conclusion References 13: Fetal Renal Artery 13.1 Embryology 13.2 Anatomy 13.3 Urine Production 13.4 Blood Flow in the Aorta and Through the Fetal Kidneys by Gestational Age 13.5 The Renal Artery Blood Flow and Resistance 13.6 Ultrasound Assessment of the Fetal Kidney 13.7 Methods to Quantify Fetal Renal Artery Flow and Resistance 13.8 Normal Values over Gestational Age 13.9 Changes with FGR 13.10 Changes with Fetal Anemia 13.11 Changes Associated with Oligohydramnios or Polyhydramnios 13.12 Changes with Renal Anomalies 13.13 Changes with Exposure to Medications References 14: Umbilical Doppler Velocimetry: Normative Data and Diagnostic Efficacy 14.1 Introduction 14.2 Doppler Interrogation of the Umbilical Artery 14.3 Pulsed-Wave Doppler Interrogation 14.4 Continuous-Wave Doppler Interrogation 14.5 Doppler Display and Archiving 14.6 Descriptor Indices of the Umbilical Arterial Doppler Waveform 14.7 Reproducibility of Umbilical Arterial Doppler Indices 14.8 Continuous-Wave Versus Pulsed-Wave Doppler Indices 14.9 Factors Influencing the Umbilical Artery Doppler Indices 14.9.1 Doppler Sampling Site 14.9.2 Short-Term Temporal Variations: The Circadian Rhythm 14.9.3 Long-Term Temporal Variations: Gestational Age Effect 14.9.4 Fetal Heart Rate 14.9.5 Fetal Breathing 14.9.6 Behavioral States 14.9.7 Blood Viscosity 14.9.8 Maternal Posture and Umbilical Arterial Doppler Indices 14.9.9 Maternal Exercise and Yoga 14.10 Reference Ranges for Umbilical Artery Doppler Indices References 15: Fetal Aortic Isthmus and Descending Aorta 15.1 Fetal Aortic Isthmus 15.1.1 Importance 15.1.2 Anatomical Features 15.1.3 Doppler Recordings of the Aortic Isthmus Flow Velocity 15.1.4 Fetal Growth Restriction 15.1.4.1 Intrauterine Hypoxia and Changes in the Aortic Isthmus Blood Flow 15.1.4.2 Early-Onset Fetal Growth Restriction 15.1.4.3 Late-Onset Fetal Growth Restriction 15.1.5 Aortic Isthmus and Coarctation of the Aorta 15.1.6 Aortic Isthmus in Twin Pregnancies 15.1.7 Maternal Hyperoxygenation and Aortic Isthmus 15.2 Fetal Descending Aorta 15.2.1 Fetal Aortic Doppler Velocimetry 15.2.1.1 Aortic Flow Estimation 15.2.1.2 Aortic Velocity Waveform Analysis 15.2.2 Fetal Aortic Flow in Uncomplicated Pregnancies 15.2.3 Intrinsic Influences on Fetal Aortic Flow and Flow Indices 15.2.4 Fetal Aortic Blood Flow during Labor 15.2.5 Pathophysiologic Changes of Fetal Aortic Flow during Intrauterine Hypoxia 15.2.6 Clinical Studies 15.2.6.1 Fetal Cardiac Arrhythmias 15.2.6.2 Fetal Anemia 15.2.6.3 Diabetes Mellitus 15.2.6.4 Fetal Growth Restriction 15.2.7 Aortic Doppler Velocimetry as a Diagnostic Test of FGR and Fetal Hypoxia 15.3 Summary References 16: The Cerebroplacental Ratio and Hypoxic Index in the Prediction of Fetal Outcome 16.1 Fetal Cerebral Flow Adaptation to Hypoxia 16.2 Examination Technique 16.2.1 Human Investigations (Duplex B, Pulsed Wave Doppler, and Color Doppler) 16.2.2 Animal Investigations (Implanted Doppler Sensors) 16.3 Cerebral Hemodynamics and Doppler Indices 16.3.1 Cerebral Resistance to Flow 16.3.2 The Cerebroplacental (Cerebral-Umbilical) Ratio: The History 16.3.3 Cerebroplacental Ratio for Evaluating pO2 Changes 16.3.4 Effect of Fetal Heart Rate on Doppler Vascular Resistance Indices 16.3.5 The Cumulative Reduction in the CPR and the Hypoxic Index 16.4 Cerebral Circulation in Normal Pregnancy 16.4.1 Cerebral Flow Changes with Gestational Age 16.4.2 Variations According to the Site of Examination 16.4.3 Cerebral Flow Changes with Behavioral States 16.5 Clinical Significance of Cerebral and Cerebral/Umbilical Indices 16.5.1 Cerebral Flow in Growth-Restricted and Hypoxic Human Fetuses 16.5.2 Cerebroplacental Ratio Change in Cases of Hypoxia and IUGR 16.5.3 Cerebroplacental Ratio and Perinatal Outcome 16.5.4 Hypoxic Index for Predicting Effect of Hypoxia 16.5.5 Cerebrovascular Reactivity Tests (O2, CO2) 16.6 Cerebral Flow Response to Induced Hypoxia and Drugs in Animal Models 16.6.1 Cerebroplacental Ratio and Mechanically Induced Hypoxia 16.6.2 Cerebral Flow and Long-Term Nicotine Treatment (Animal Model) 16.6.3 Cerebral Flow and Long-Term Cocaine Treatment (Animal Model) 16.6.4 Cerebroplacental Ratio and Acute Drug Effect 16.7 Cerebral Resistance Index, Flow Redistribution Ratio (CPR), and Hypoxic Index in Specific Human Pathologies 16.7.1 Cerebral Resistance Index and CPR in Acute Reversible Hypoxia: Prediction of Abnormal Fetal Heart Rate at Delivery 16.7.1.1 Without Placental Insufficiency: Maternal Anemia 16.7.1.2 With Placenta Insufficiency (Malaria) 16.7.2 CPR in Nonreversible Hypoxia (Hypertension in Pregnancy) Prediction of Abnormal Fetal Heart Rate at Delivery 16.7.3 Cerebral Flow During Maternal Anesthesia 16.8 CPR Change During Febrile Episodes 16.9 Clinical Effectiveness and Guidelines 16.10 Summary of the Design, Validation, and Significance of the Cerebroplacental Ratio and the Hypoxic Index 16.11 Conclusion References 17: The Cerebroplacental Ratio 17.1 Fetal Brain Circulation and Hypoxia 17.2 Fetal Brain Circulation 17.3 Fetal Size/Growth and Brain Circulation 17.4 Fetal Brain-Sparing and Brain Vasodilation 17.5 Pioneering Studies on the Cerebroplacental Ratio 17.6 Normal Values of the Cerebroplacental Ratio 17.7 Longitudinal Changes of the Cerebroplacental Ratio 17.8 Should the Cerebroplacental Ratio Be Evaluated in all Pregnant Women? 17.9 Can a Reduced Cerebroplacental Ratio Predict an Abnormal Fetal Heart Rate During Labor? 17.10 The Cerebroplacental Ratio in Fetal Growth Restriction 17.11 The Cerebroplacental Ratio in Other High Risk Conditions 17.12 The Cerebroplacental Ratio and Maternal Serum Biomarkers 17.13 Conclusion References 18: Cerebral Blood Flow Velocity Waveforms and Fetal Anemia 18.1 Causes of Fetal Anemia 18.2 Which Cerebral Vessel to Assess 18.3 Technique for Measurement of Middle Cerebral Artery Doppler 18.4 Historical Development of Middle Cerebral Artery Technique 18.5 Practical Application of MCA Peak Systolic Velocity to Red Cell Alloimmunization 18.6 False Positives with Middle Cerebral Doppler 18.7 The Middle Cerebral Doppler in Alloimmunization 18.8 The Middle Cerebral Doppler in Infection 18.9 The Middle Cerebral Doppler in Fetal Hydrops 18.10 The Middle Cerebral Doppler in Twin Anemia-Polycythemia Syndrome 18.11 The Middle Cerebral Doppler in Fetomaternal Hemorrhage References 19: First- and Second-Trimester Doppler Velocimetry of the Uteroplacental Circulation 19.1 Physiological Changes in the Uteroplacental Circulation During Pregnancy 19.1.1 Abnormal Changes in the Uteroplacental Circulation 19.2 Relationship Between the Uteroplacental Circulation and the Maternal Systemic Circulation 19.3 First-Trimester Doppler Velocimetry of the Uteroplacental Circulation for the Prediction of Fetal Growth Restriction and Pre-eclampsia 19.4 Protocol for Recording the Uterine Artery Doppler in the First Trimester 19.5 First-Trimester-Combined Screening Algorithms for Fetal Growth Restriction and Pre-eclampsia 19.5.1 Maternal Risk Factors 19.5.2 Serum Biomarkers 19.5.3 The Uterine Artery Pulsatility Index in Combination with Other Tests 19.6 Second-Trimester Doppler Velocimetry of the Uteroplacental Circulation for the Prediction of Fetal Growth Restriction and Pre-eclampsia 19.7 Protocol for Recording the Uterine Artery Doppler in the Second Trimester 19.8 Second-Trimester-Combined Screening Algorithms for Fetal Growth Restriction and Pre-eclampsia 19.9 Third-Trimester-Combined Screening Algorithms for Fetal Growth Restriction and Pre-eclampsia 19.10 Longitudinal Screening for Changes in Doppler Velocimetry of the Uteroplacental Circulation for the Prediction of Fetal Growth Restriction and Pre-eclampsia 19.11 Limitations of Doppler Velocimetry of the Uteroplacental Circulation 19.12 Effect of Low-Dose Aspirin on the Uteroplacental Circulation during Pregnancy in Women at a Risk of Developing Pre-eclampsia 19.12.1 Pharmacology in Pre-eclampsia 19.13 Conclusions References 20: Uterine Doppler Velocimetry and Hypertensive Disease 20.1 Introduction 20.2 Technical Considerations 20.3 Role of Uterine Artery Velocimetry in the Prediction of Hypertensive Disorders of Pregnancy 20.4 Role of Uterine Artery Velocimetry in the Prediction of Hypertensive Disorders of Pregnancy in Low- and High-Risk Women 20.5 Role of Doppler Velocimetry of the Uterine Arteries in the Prediction of Early-Onset vs Late-Onset Pre-eclampsia 20.6 Role of Doppler Velocimetry of the Uterine Arteries in the First and Second Trimesters 20.7 Longitudinal Changes in Uterine Artery Doppler Indices 20.8 Role of Uterine Artery Doppler in the Management of Hypertensive Disorders of Pregnancy 20.9 Insights into the Dual Etiology of Pre-eclampsia: Role of the Assessment of Uterine Artery Doppler References 21: Fetal Doppler Velocimetry in Monochorionic Pregnancy: Twin Reversed Arterial Perfusion, Twin-to-Twin Transfusion Syndrome, and Twin Anemia Polycythemia Sequence 21.1 Twin Pregnancies 21.1.1 Diagnosis of Dichorionic Versus Monochorionic Pregnancies 21.1.2 Vascular Anastomoses 21.2 Adverse Outcomes in Monochorionic Pregnancies 21.2.1 Growth Discordance 21.2.2 Twin-to-Twin Transfusion Syndrome 21.2.3 Twin Anemia Polycythemia Sequence 21.2.4 Twin Reversed Arterial Perfusion Sequence 21.2.5 Other Complications 21.3 Imaging Modalities Used in the Assessment of Monochorionic Pregnancies 21.3.1 Doppler Velocimetry 21.3.1.1 Umbilical Artery Doppler 21.3.1.2 Middle Cerebral Artery Doppler 21.3.1.3 Ductus Venosus Doppler 21.3.1.4 Umbilical Vein Doppler 21.3.1.5 The Umbilical Arterial-Venous Index 21.3.2 Placental Anastomosis Mapping 21.3.2.1 Two-Dimensional (2D) Ultrasound Mapping Arteriovenous Anastomoses Arterio-Arterial Anastomoses Venovenous Anastomoses 21.3.2.2 3D Mapping 21.3.2.3 MRI Mapping 21.3.3 Intra-cardiac Doppler 21.3.3.1 Fetal Cardiovascular Hemodynamics in TTTS 21.3.3.2 The Recipient Functional Pulmonary Atresia/Stenosis Myocardial Performance (Tei) Index (MPI) Assessment of Myocardial Deformation Speckle Tracking Spectral Tissue Doppler Imaging Aortic Fractional Area Change (AFAC) The Aortic Isthmus Systolic Index (ISI) 21.3.3.3 The Donor 21.3.3.4 Assessment of Post-laser Ablation References 22: Doppler Sonography in Pregnancies Complicated by Pre-gestational Diabetes Mellitus 22.1 Introduction 22.2 Maternal Glycemic State and Fetal Hemodynamics 22.2.1 Hyperglycemia and Fetal Hemodynamics 22.2.2 Hypoglycemia and Fetal Hemodynamics 22.3 Umbilical Artery Doppler Sonography in Diabetic Pregnancies 22.3.1 Umbilical Artery Doppler and Perinatal Outcomes 22.3.2 Umbilical Arterial Doppler Sonography and Maternal Glycemic Control 22.4 Doppler Sonography of Other Fetal and Uterine Circulations in Pre-Gestational Diabetic Pregnancies 22.4.1 Fetal Middle Cerebral Artery Doppler 22.4.2 Doppler Analysis of the Fetal Venous System 22.4.3 Fetal Cardiac Doppler 22.4.4 Uterine Artery Doppler 22.4.5 Doppler Analysis of Placental Vascularization 22.5 Clinical Effectiveness and Guidelines 22.6 Conclusions References 23: Doppler Velocimetry in Prolonged Pregnancy 23.1 Introduction 23.2 Other Vessels 23.2.1 Aortic Blood Flow Doppler 23.2.2 Pulmonary Artery Doppler 23.2.3 Renal Artery Doppler 23.2.4 Uterine Artery Doppler 23.3 Umbilical and Middle Cerebral Artery Doppler 23.4 Conclusions References 24: Umbilical Artery Doppler for Fetal Surveillance: Diagnostic Efficacy 24.1 Introduction 24.2 Diagnostic Efficacy in High-Risk Pregnancies 24.3 Umbilical Artery Doppler, Non-Stress Test, and Biophysical Profile: Comparative Efficacy 24.4 Fetal Asphyxia and Umbilical Doppler Indices 24.5 Fetal Doppler Sonography and Neurodevelopmental Outcome 24.6 Efficacy of Doppler Sonography for Screening Low-Risk and Unselected Pregnancies References 25: Absent End-Diastolic Velocity in the Umbilical Artery and Its Clinical Significance 25.1 Introduction 25.2 Incidence 25.3 Technical Considerations 25.4 Absent End-Diastolic Velocity and Its Adverse Consequences 25.5 Perinatal Mortality 25.6 Perinatal Morbidity 25.7 Congenital Malformations and Chromosomal Abnormalities 25.8 Fetal Growth Restriction 25.9 Fetal Asphyxia and Hypoxemia 25.10 Cerebral Hemorrhage 25.11 Necrotizing Enterocolitis 25.12 Hematological Changes 25.13 Hypoglycemia 25.14 Neurodevelopmental Sequelae 25.15 Maternal Hypertension and Absent End-Diastolic Velocity 25.16 Reappearance of End-Diastolic Velocity 25.17 Sequence of Changes in Fetal Surveillance Parameters with Progressive Antepartum Fetal Compromise References 26: Fetal Doppler Velocimetry in High-Risk Pregnancies: Randomized Clinical Trials 26.1 Introduction 26.2 Trials of Umbilical Artery Doppler in High-Risk Pregnancies 26.2.1 Evidence from Randomized Studies 26.2.2 Implication for Practice 26.3 Trials of Ductus Venosus Doppler in High-Risk Pregnancies 26.3.1 Evidence from Randomized Studies 26.3.2 Implication for Practice 26.4 Trials of Middle Cerebral Artery Doppler or its Ratio to the Umbilical Artery in High-Risk Pregnancies 26.4.1 Evidence from Randomized Studies 26.4.2 Implication for Practice 26.5 Implications for Research References 27: Doppler Interrogation of the Umbilical Venous Flow 27.1 Introduction 27.2 Fetal Flow Volume Measurements in the Era of Digital Computing and Imaging 27.2.1 Sources of Inaccuracies 27.2.2 Source of Accuracy 27.2.3 Volume Flow Values and Problems of Standardization 27.2.4 Comparison Between Non-invasive Doppler Volume Flow Values and Experimental Research 27.3 The Relationship of Umbilical Vein Blood Flow with Growth in the Human Fetus 27.4 Clinical Value of Umbilical Vein Blood Flow in Severe Fetal Growth Restriction 27.5 Diagnostic Usage of Umbilical Vein Blood Flow in Late Growth Restriction and in “Constitutionally Small Fetuses” References 28: The Ductus Venosus 28.1 Historical Background 28.2 Functional Anatomy 28.3 Hemodynamic Background 28.3.1 Via Sinistra and Via Dextra 28.3.2 The Distributional Unit Ductus Venosus–Foramen Ovale 28.3.3 Distribution to the Ductus Venosus or Liver Perfusion 28.3.4 The Umbilicocaval (Portosystemic) Pressure Gradient 28.3.5 Abdominal–Thoracic Pressure Difference 28.3.6 Ultrasound Gray-Scale Imaging 28.3.7 Color Doppler Imaging 28.3.8 Pulsed Wave Doppler Recording 28.3.9 Normal Ductus Venosus Blood Velocity 28.3.10 Waveform Analysis 28.3.11 Interpretation of the Waveform: A-Wave 28.3.12 A-Wave in Early Pregnancy 28.3.13 Interpretation of the Systolic Wave 28.4 Pitfalls 28.5 Reproducibility 28.6 Agenesis of the Ductus Venosus 28.7 Immediate Postnatal Development References 29: Doppler Examination of the Fetal Pulmonary Venous Circulation 29.1 Introduction 29.1.1 Pulmonary Venous Anatomy and Embryology 29.1.2 Fetal Pulmonary Vein Physiology 29.2 Approach to Imaging of the Pulmonary Veins 29.2.1 2D Assessment 29.2.2 Color Doppler Assessment 29.2.3 Pulsed Wave (PW) Doppler Assessment 29.2.4 Power Doppler and Microflow Imaging Modalities 29.2.5 3D and 4D Fetal Pulmonary Vein Imaging with STIC, TUI, and B-Flow 29.3 Congenital Anomalies of the Pulmonary Venous System 29.3.1 Total Anomalous Pulmonary Venous Return (TAPVR) 29.3.1.1 Supracardiac TAPVR 29.3.1.2 Intracardiac TAPVR 29.3.1.3 Infracardiac TAPVR 29.3.1.4 Mixed TAPVR 29.3.2 Partial Anomalous Pulmonary Venous Return (PAPVR) 29.3.2.1 PAPVR with Sinus Venosus Atrial Septal Defect 29.3.2.2 PAPVR in Scimitar Syndrome 29.3.2.3 PAPVR of the Left Pulmonary Veins 29.3.3 Other Rare Pulmonary Venous Anomalies 29.3.3.1 Cor Triatriatum Sinister 29.4 Utility of Pulmonary Venous Doppler in Setting of Cardiac Disease 29.5 Role for PV Doppler in Diagnosis of Fetal Arrhythmia 29.6 Role for Prenatal Diagnosis Improving Perinatal Management 29.7 Summary References 30: Introduction to Fetal Doppler Echocardiography 30.1 Introduction 30.2 General Considerations 30.3 Choice of Equipment for Doppler Echocardiography 30.4 Doppler Modalities for Fetal Echocardiography 30.4.1 Fetal Cardiac Color Doppler 30.4.2 Fetal Cardiac Spectral Doppler 30.4.3 Fetal Cardiac M-Mode 30.4.4 Fetal Cardiac Tissue Doppler 30.5 Indications for Fetal Echocardiography 30.6 Method of Fetal Doppler Echocardiography 30.7 Doppler Assessment of Fetal Cardiac Hemodynamics 30.7.1 Atrial Flow 30.7.2 Atrioventricular: Tricuspid and Mitral Flow 30.7.3 Ventricular Outflows: Pulmonary Artery and Aorta 30.7.4 Doppler Determination of Myocardial Performance Index 30.7.5 Doppler Determination of Fetal Cardiac Output 30.7.6 Cardiac Output: Normative Data 30.7.7 Right Heart Versus Left Heart Dominance 30.7.8 Limitations of Cardiac Output Measurement 30.8 Doppler Echocardiography During Early Pregnancy References 31: Fetal Echocardiography to Plan Postnatal Management in Fetuses with Congenital Heart Disease 31.1 Introduction 31.2 Fetal Circulation/Doppler Assessment Under Normal Conditions and in the Presence of CHD 31.3 Doppler in Fetal Echocardiography to Risk Stratify and Plan Postnatal Management 31.4 Low-Risk CHD 31.4.1 Shunt Lesions 31.4.2 Valve Abnormalities 31.5 Minimal-Risk CHD 31.5.1 Pulmonary Obstruction 31.5.1.1 Systemic Outflow Obstruction 31.6 High-Risk CHD 31.6.1 CHD Dependent on FO Patency 31.6.2 CHD Resulting in Diminished Systemic Perfusion References 32: Doppler Echocardiography of Fetal Cardiac Arrhythmias 32.1 Introduction 32.2 Methods and Techniques of Fetal Cardiac Activity Assessment 32.3 Fetal Arrhythmias 32.4 Bradyarrhythmia 32.5 Tachyarrhythmias References 33: 4D Fetal Doppler Echocardiography 33.1 Introduction 33.2 Historical Perspective of Spatiotemporal Imaging Technology (STIC) and the Incorporation of Color and Power Doppler Imaging Modalities 33.3 Newer Applications of Color and Power Doppler STIC Technology 33.3.1 First Trimester Rendered Images of the Cardiovascular System 33.3.2 Second and Third Trimester Identification of Complicated Arch Anomalies and Pulmonary Veins 33.3.3 Second and Third Trimester Identification of the Location of Ventricular Septal Defects 33.4 Benefits of STIC Color and Power Image Acquisition References 34: Cardiac Function in Fetal Growth Restriction 34.1 Introduction 34.2 Early FGR 34.3 Late Fetal Growth Restriction References 35: Role of Ultrasonography in Placenta Accreta Spectrum 35.1 Introduction, Epidemiology and Risk Factors 35.2 Clinical Implications 35.3 Ultrasound Findings 35.4 Color Doppler Ultrasound 35.5 3D and Power Doppler Imaging 35.6 Technical Aspects [16] 35.6.1 Bladder Volume [25] 35.6.2 Angle of Insonation 35.6.3 Transabdominal and Transvaginal Probe Pressure 35.6.4 Color Doppler and (3D) Power Doppler 35.7 Clinical Examples 35.7.1 Clinical Cases-Imaging-Related to Clinical Findings During Surgery References 36: Three-Dimensional Doppler Ultrasound in Gynecology 36.1 Technique 36.2 3D Doppler Measurements 36.3 3D Doppler in Human Reproduction 36.4 3D Doppler in Gynecologic Oncology 36.5 3D Doppler in Benign Gynecology 36.6 Conclusion References 37: Doppler Ultrasound in Early Pregnancy Including Miscarriage, Ectopic Pregnancy, and Implantation 37.1 Introduction 37.1.1 Types of Doppler and Their Application in Early Pregnancy 37.1.2 Normal Pelvic Blood Flow During the Ovulation, Luteal Phase, Implantation, and Early Pregnancy: General Concepts 37.2 Early Pregnancy States: Definitions 37.3 Role of Doppler Ultrasound in the Diagnosis of Intrauterine Viable Pregnancies 37.4 Role of Doppler Ultrasound in the Diagnosis of Intra-cavitary Retained Products of Conception (RPOC) 37.5 Role of Doppler Ultrasound in the Diagnosis of Ectopic Pregnancies 37.6 Role of Doppler Ultrasound in the Diagnosis of Gestational Trophoblastic Disease 37.7 Safety of Ultrasound During Early Pregnancy 37.8 Conclusions References 38: Doppler in Benign and Malignant Conditions of the Ovary 38.1 Introduction 38.2 The Normal Ovary and Its Circulation 38.3 Effect of Pathology on the Ovarian Circulation 38.4 Role of Ultrasound and Doppler in the Assessment of Ovarian Tumors 38.4.1 Pulsed Doppler 38.4.2 Color Doppler 38.4.3 Other Methods 38.5 Role of Ovarian Doppler in Early Pregnancy 38.5.1 The Corpus Luteum 38.5.2 Ovarian Ectopic Pregnancy 38.5.3 Decidualized Endometrioma 38.6 Other Conditions Affecting the Ovary 38.6.1 Ovarian Torsion 38.6.2 Pelvic Inflammatory Disease 38.7 Non-ovarian Pathology 38.7.1 Pedunculated Fibroid 38.7.2 Peritoneal Pseudocysts 38.7.3 Pelvic Kidney 38.8 Conclusion References 39: Doppler in Benign and Malignant Conditions of the Uterus 39.1 Introduction 39.2 Myometrium and Myometrial Lesions 39.2.1 Normal Myometrium 39.2.2 Benign Lesions 39.2.2.1 Fibroids 39.2.2.2 Adenomyosis 39.2.3 Malignant Lesions 39.3 Endometrium and Intracavitary Lesions 39.3.1 Physiological Changes 39.3.2 Benign Lesions 39.3.2.1 Endometrial Polyps 39.3.2.2 Intracavitary Fibroids 39.3.2.3 Retained Products of Conception (RPOC) 39.3.3 Malignant Lesions 39.3.3.1 Endometrial Cancer 39.4 Miscellaneous References