Meta-Analysis

. 2013 Nov 12;2013(11):CD007529.

doi: 10.1002/14651858.CD007529.pub3.

Fetal and umbilical Doppler ultrasound in high-risk pregnancies

Zarko Alfirevic¹, Tamara Stampalija, Gillian M L Gyte

Affiliations

Affiliation

¹ Department of Women's and Children's Health, The University of Liverpool, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK, L8 7SS.

PMID: 24222334
PMCID: PMC6464948
DOI: 10.1002/14651858.CD007529.pub3

Meta-Analysis

Fetal and umbilical Doppler ultrasound in high-risk pregnancies

Zarko Alfirevic et al. Cochrane Database Syst Rev. 2013.

. 2013 Nov 12;2013(11):CD007529.

doi: 10.1002/14651858.CD007529.pub3.

Authors

Zarko Alfirevic¹, Tamara Stampalija, Gillian M L Gyte

Affiliation

¹ Department of Women's and Children's Health, The University of Liverpool, First Floor, Liverpool Women's NHS Foundation Trust, Crown Street, Liverpool, UK, L8 7SS.

PMID: 24222334
PMCID: PMC6464948
DOI: 10.1002/14651858.CD007529.pub3

Update in

Fetal and umbilical Doppler ultrasound in high-risk pregnancies.
Alfirevic Z, Stampalija T, Dowswell T. Alfirevic Z, et al. Cochrane Database Syst Rev. 2017 Jun 13;6(6):CD007529. doi: 10.1002/14651858.CD007529.pub4. Cochrane Database Syst Rev. 2017. PMID: 28613398 Free PMC article.

Abstract

Background: Abnormal blood flow patterns in fetal circulation detected by Doppler ultrasound may indicate poor fetal prognosis. It is also possible false positive Doppler ultrasound findings could encourage inappropriate early delivery.

Objectives: The objective of this review was to assess the effects of Doppler ultrasound used to assess fetal well-being in high-risk pregnancies on obstetric care and fetal outcomes.

Search methods: We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 30 September 2013.

Selection criteria: Randomised and quasi-randomised controlled trials of Doppler ultrasound for the investigation of umbilical and fetal vessels waveforms in high-risk pregnancies compared with no Doppler ultrasound.

Data collection and analysis: Two review authors independently assessed the studies for inclusion, assessed risk of bias and carried out data extraction. Data entry was checked.

Main results: Eighteen completed studies involving just over 10,000 women were included. The trials were generally of unclear quality with some evidence of possible publication bias. The use of Doppler ultrasound in high-risk pregnancy was associated with a reduction in perinatal deaths (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.52 to 0.98, 16 studies, 10,225 babies, 1.2% versus 1.7 %, number needed to treat (NNT) = 203; 95% CI 103 to 4352). There were also fewer inductions of labour (average RR 0.89, 95% CI 0.80 to 0.99, 10 studies, 5633 women, random-effects) and fewer caesarean sections (RR 0.90, 95% CI 0.84 to 0.97, 14 studies, 7918 women). No difference was found in operative vaginal births (RR 0.95, 95% CI 0.80 to 1.14, four studies, 2813 women), nor in Apgar scores less than seven at five minutes (RR 0.92, 95% CI 0.69 to 1.24, seven studies, 6321 babies).

Authors' conclusions: Current evidence suggests that the use of Doppler ultrasound in high-risk pregnancies reduced the risk of perinatal deaths and resulted in less obstetric interventions. The quality of the current evidence was not of high quality, therefore, the results should be interpreted with some caution. Studies of high quality with follow-up studies on neurological development are needed.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

**Figure 1**
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

**Figure 2**
Funnel plot of comparison: 1 Doppler ultrasound versus no Doppler ultrasound, outcome: 1.1 Any perinatal death after randomisation.

**Figure 3**
Funnel plot of comparison: 1 Doppler ultrasound versus no Doppler ultrasound, outcome: 1.8 Cesarean section (elective and emergency).

**Figure 4**
Funnel plot of comparison: 1 Doppler ultrasound versus no Doppler ultrasound, outcome: 1.9 Cesarean section ‐ elective.

**Figure 5**
Funnel plot of comparison: 1 Doppler ultrasound versus no Doppler ultrasound, outcome: 1.10 Cesarean section ‐ emergency.

**Analysis 1.1**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 1 Any perinatal death after randomisation.

**Analysis 1.2**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 2 Serious neonatal morbidity.

**Analysis 1.3**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 3 Stillbirth.

**Analysis 1.4**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 4 Neonatal death.

**Analysis 1.5**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 5 Any potentially preventable perinatal death*.

**Analysis 1.7**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 7 Apgar < 7 at 5 minutes.

**Analysis 1.8**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 8 Caesarean section (elective and emergency).

**Analysis 1.9**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 9 Caesarean section ‐ elective.

**Analysis 1.10**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 10 Caesarean section ‐ emergency.

**Analysis 1.11**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 11 Spontaneous vaginal birth.

**Analysis 1.12**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 12 Operative vaginal birth.

**Analysis 1.13**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 13 Induction of labour.

**Analysis 1.16**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 16 Infant requiring intubation/ventilation.

**Analysis 1.17**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 17 Neonatal fitting/seizures.

**Analysis 1.18**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 18 Preterm labour.

**Analysis 1.19**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 19 Infant respiratory distress syndrome (RDS).

**Analysis 1.21**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 21 Neonatal admission to SCBU and/or NICU.

**Analysis 1.22**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 22 Hypoxic ischaemic encephalopathy.

**Analysis 1.23**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 23 Intraventricular haemorrhage.

**Analysis 1.28**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 28 Gestational age at birth.

**Analysis 1.29**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 29 Birth weight.

**Analysis 1.30**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 30 Length of infant hospital stay.

**Analysis 1.31**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 31 Birth < 34 weeks (not prespecified).

**Analysis 1.32**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 32 Antenatal admissions (not prespecified).

**Analysis 1.33**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 33 Phototherapy for neonatal jaundice (not prespecified).

**Analysis 1.34**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 34 Abnormal neurological development at 9months (not pre‐specified).

**Analysis 1.35**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 35 Hospitalisation for IUGR neonatal (not prespecified).

**Analysis 1.36**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 36 Fetal distress in labour (not prespecified).

**Analysis 1.37**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 37 Birth weight < 5 percentile (not prespecified).

**Analysis 1.38**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 38 Periventricular leucomalacia (not prespecified).

**Analysis 1.39**
Comparison 1 Doppler ultrasound versus no Doppler ultrasound, Outcome 39 Antenatal hospital stay.

**Analysis 2.1**
Comparison 2 Doppler ultrasound versus no Doppler ultrasound (all subgroups), Outcome 1 Any perinatal death after randomisation.

**Analysis 2.2**
Comparison 2 Doppler ultrasound versus no Doppler ultrasound (all subgroups), Outcome 2 Serious neonatal morbidity.

**Analysis 3.1**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 1 Any perinatal death after randomisation.

**Analysis 3.3**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 3 Stillbirth.

**Analysis 3.4**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 4 Neonatal death.

**Analysis 3.5**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 5 Any potentially preventable perinatal death*.

**Analysis 3.7**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 7 Apgar < 7 at 5 minutes.

**Analysis 3.8**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 8 Caesarean section (elective and emergency).

**Analysis 3.9**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 9 Caesarean section ‐ elective.

**Analysis 3.10**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 10 Caesarean section ‐ emergency.

**Analysis 3.11**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 11 Spontaneous vaginal birth.

**Analysis 3.12**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 12 Operative vaginal birth.

**Analysis 3.13**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 13 Induction of labour.

**Analysis 3.16**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 16 Infant requiring intubation/ventilation.

**Analysis 3.17**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 17 Neonatal fitting/seizures.

**Analysis 3.21**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 21 Neonatal admission to SCBU and/or NICU.

**Analysis 3.28**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 28 Gestational age at birth.

**Analysis 3.29**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 29 Birth weight.

**Analysis 3.30**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 30 Length of infant hospital stay.

**Analysis 3.32**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 32 Antenatal admissions (not pre‐specified).

**Analysis 3.33**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 33 Phototherapy for neonatal jaundice (not pre‐specified).

**Analysis 3.39**
Comparison 3 Doppler ultrasound alone versus CTG alone, Outcome 39 Antenatal hospital stay.

**Analysis 4.1**
Comparison 4 Doppler ultrasound alone versus CTG alone (all subgroups), Outcome 1 Any perinatal death after randomisation.

**Analysis 5.1**
Comparison 5 Doppler ultrasound versus no Doppler ultrasound ‐ SGA/IUGR, Outcome 1 Any perinatal death after randomisation (SGA/IUGR).

**Analysis 6.1**
Comparison 6 Doppler ultrasound alone versus CTG ‐ SGA/IUGR, Outcome 1 Any perinatal death after randomisation (SGA/IUGR).

**Analysis 7.1**
Comparison 7 Doppler ultrasound versus no Doppler ultrasound ‐ in hypertension/pre‐eclampsia, Outcome 1 Any perinatal death after randomisation (hypertension/pre‐eclampsia).

**Analysis 8.1**
Comparison 8 Doppler ultrasound versus CTG ‐ in hypertension/pre‐eclampsia, Outcome 1 Any perinatal death after randomisation (hypertension/pre‐eclampsia).

See this image and copyright information in PMC

Update of

Fetal and umbilical Doppler ultrasound in high-risk pregnancies.
Alfirevic Z, Stampalija T, Gyte GM. Alfirevic Z, et al. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007529. doi: 10.1002/14651858.CD007529.pub2. Cochrane Database Syst Rev. 2010. Update in: Cochrane Database Syst Rev. 2013 Nov 12;(11):CD007529. doi: 10.1002/14651858.CD007529.pub3. PMID: 20091637 Free PMC article. Updated.

Cited by

Ultrasound's 'window on the womb' brings ethical challenges for balancing maternal and fetal health interests: obstetricians' experiences in Australia.
Edvardsson K, Small R, Lalos A, Persson M, Mogren I. Edvardsson K, et al. BMC Med Ethics. 2015 May 8;16:31. doi: 10.1186/s12910-015-0023-y. BMC Med Ethics. 2015. PMID: 25953252 Free PMC article.
Impact of umbilical cord length on fetal circulatory system by Doppler assessment.
Olaya-C M, Vargas W, Martinez RA, Peñaloza IF, Sanchez M, Madariaga I, Aldana S, Bernal JE. Olaya-C M, et al. J Ultrasound. 2020 Dec;23(4):585-592. doi: 10.1007/s40477-020-00495-2. Epub 2020 Jul 11. J Ultrasound. 2020. PMID: 32654041 Free PMC article.
Maternal plasma syndecan-1: a biomarker for fetal growth restriction.
Juusela A, Jung E, Gallo DM, Bosco M, Suksai M, Diaz-Primera R, Tarca AL, Than NG, Gotsch F, Romero R, Chaiworapongsa T. Juusela A, et al. J Matern Fetal Neonatal Med. 2023 Dec;36(1):2150074. doi: 10.1080/14767058.2022.2150074. J Matern Fetal Neonatal Med. 2023. PMID: 36597808 Free PMC article.
Sex differences in umbilical artery Doppler indices: a longitudinal study.
Widnes C, Flo K, Wilsgaard T, Kiserud T, Acharya G. Widnes C, et al. Biol Sex Differ. 2018 Apr 18;9(1):16. doi: 10.1186/s13293-018-0174-x. Biol Sex Differ. 2018. PMID: 29669590 Free PMC article.
Cluster Randomised Trials in Cochrane Reviews: Evaluation of Methodological and Reporting Practice.
Richardson M, Garner P, Donegan S. Richardson M, et al. PLoS One. 2016 Mar 16;11(3):e0151818. doi: 10.1371/journal.pone.0151818. eCollection 2016. PLoS One. 2016. PMID: 26982697 Free PMC article.

See all "Cited by" articles

References

References to studies included in this review

1. Almstrom H, Axelsson O, Cnattingius S, Ekman G, Maesel A, Ulmsten U, et al. Comparison of umbilical‐artery velocimetry and cardiotocography for surveillance of small‐for‐gestational‐age fetuses. Lancet 1992;340:936‐40. - PubMed
2. Almstrom H, Axelsson O, Ekman G, Ingemarsson I, Maesel A, Arstrom K, et al. Umbilical artery velocimetry may influence clinical interpretation of intrapartum cardiotocograms. Acta Obstetricia et Gynecologica Scandinavica 1995;74:526‐9. - PubMed
3. Marsal K, Almstrom H, Axelsson O, Cnattingius S, Ekman G, Maesel A, et al. Umbilical artery velocimetry is more effective than cardiotocography for surveillance of growth retarded fetuses. Journal of Perinatal Medicine 1991;19(Suppl 2):84.
1. Biljan M, Haddad N, McVey K, Williams J. Efficiency of continuous‐wave Doppler in screening high risk pregnancies in a district general hospital (a prospective randomized study on 674 singleton pregnancies). Proceedings of 26th British Congress of Obstetrics and Gynaecology; 1992 July 7‐10; Manchester, UK. 1992:6.
2. Biljan MM, McVey KP, Haddad NG. The value of continuous wave doppler assessment of fetal umbilical artery in management of "at risk" pregnancies. Proceedings of 2nd European Congress on Prostaglandins in Reproduction; 1991 April 30‐May 3; The Hague, Netherlands. 1991:189.
1. Burke G, Stuart B, Crowley P, Ni Scanaill S, Drumm J. Does Doppler ultrasound alter the management of high‐risk pregnancy?. Care concern and cure in perinatal medicine. 13th European Congress of Perinatal Medicine; 1992 May; Amsterdam, The Netherlands. Parthenon, 1992:597‐604.
2. Burke G, Stuart B, Crowley P, Ni Scanaill S, Drumm J. Does Doppler ultrasound alter the management of high‐risk pregnancy?. Journal of Perinatal Medicine 1992;20(Suppl 1):266.
1. Rochambeau B, Jabbour N, Mellier G. Umbilical doppler velocimetry in prolonged pregnancies [La velocimetrie Doppler ombilicale dans les grossesses prolongees]. Revue Francaise de Gynecologie et d Obstetrique 1992;87(5):289‐94. - PubMed
1. Giles W, Bisits A, O'Callaghan S. The doppler assessment in multiple pregnancy study (damp) and metaanalyses of doppler and twins. American Journal of Obstetrics and Gynecology 2000;182(1 Pt 2):S17.
2. Giles W, Bisits A, O'Callaghan S, Gill A. The doppler assessment in multiple pregnancy randomised controlled trial of ultrasound biometry versus umbilical artery doppler ultrasound and biometry in twin pregnancy. BJOG: an international journal of obstetrics and gynaecology 2003;110(6):593‐7. - PubMed

References to studies excluded from this review

1. Davies JA, Gallivan S, Spencer JAD. Randomised controlled trial of doppler ultrasound screening of placental perfusion during pregnancy. Lancet 1992;340:1299‐303. - PubMed
1. Gonsoulin W. Umbilical artery Doppler waveform analysis: a randomized study on effect on outcome. American Journal of Obstetrics and Gynecology 1991;164:370.
1. Mason GC, Lilford RJ, Porter J, Nelson E, Tyrell S. Randomised comparison of routine vs highly selective use of Doppler ultrasound in low risk pregnancies. British Journal of Obstetrics and Gynaecology 1993;100:130‐3. - PubMed
1. McCowan LME, Harding J, Roberts AB, Barker S, Townend K. Perinatal morbidity in small for gestational age fetuses in relation to umbilical doppler. Proceedings of the 14th Annual Congress of the Australian Perinatal Society in conjunction with the New Zealand Perinatal Society; 1996 March 24‐27; Adelaide, Australia. 1996:P10.
1. McParland P, Pearce JM. Doppler blood flow in pregnancy. Placenta 1988;9:427‐50. - PubMed

References to ongoing studies

1. Cambridge Consortium. Trial of umbilical and fetal flow in Europe (TRUFFLE) (ongoing trial). National Research Register (www.nrr.nhs.uk) (accessed 6 July 2006).
2. Lees C, Baumgartner H. The TRUFFLE study ‐ a collaborative publicly funded project from concept to reality: how to negotiate an ethical, administrative and funding obstacle course in the European Union. Ultrasound in Obstetrics and Gynecology 2005;25:105‐7. - PubMed

Additional references

1. Al‐Ghazali WH, Chapman MG, Rissik JM, Allan LD. The significance of absent end‐diastolic flow in the umbilical artery combined with reduced fetal cardiac output estimation in pregnancies at high risk for placental insufficiency. Journal of Obstetrics and Gynaecology 1990;10:271‐5.
1. Alfirevic Z, Neilson JP. Doppler ultrasonography in high‐risk pregnancies: systematic review with meta‐analysis. American Journal of Obstetrics and Gynecology 1995;172:1379‐87. - PubMed
1. Alfirevic Z, Roberts D, Martlew V. How strong is the association between maternal thrombophilia and adverse pregnancy outcome? A systematic review. European Journal Obstetetrics & Gynecology and Reproductive Biology 2002;101(1):6‐14. - PubMed
1. Alfirevic Z, Stampalija T, Gyte GML. Fetal and umbilical Doppler ultrasound in normal pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 8. [DOI: 10.1002/14651858.CD001450.pub3] - DOI - PMC - PubMed
1. Almstrom H, Axelsson O, Ekman G, Ingemarsson I, Maesel A, Arstrom K, et al. Umbilical artery velocimetry may influence clinical interpretation of intrapartum cardiotocograms. Acta Obstetricia et Gynecologica Scandinavica 1995;74:526‐9. - PubMed

References to other published versions of this review

1. Alfirevic Z, Stampalija T, Gyte GML. Fetal and umbilical Doppler ultrasound in high‐risk pregnancies. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD007529.pub2] - DOI - PMC - PubMed
1. Neilson JP, Alfirevic Z. Doppler ultrasound for fetal assessment in high risk pregnancies. Cochrane Database of Systematic Reviews 1995, Issue 1. [DOI: 10.1002/14651858.CD000073] - DOI - PubMed
1. Neilson JP, Alfirevic Z. Doppler ultrasound for fetal assessment in high risk pregnancies. Cochrane Database of Systematic Reviews 1996, Issue 4. [DOI: 10.1002/14651858.CD000073.pub2] - DOI - PubMed

Publication types

Actions
Actions
Actions

MeSH terms

Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions
Actions

LinkOut - more resources

Full Text Sources
Other Literature Sources
- scite Smart Citations
Medical
- ClinicalTrials.gov
- MedlinePlus Health Information

Save citation to file

Email citation

Add to Collections

Add to My Bibliography

Your saved search

Create a file for external citation management software

Your RSS Feed

Fetal and umbilical Doppler ultrasound in high-risk pregnancies

Affiliation

Fetal and umbilical Doppler ultrasound in high-risk pregnancies

Authors

Affiliation

Update in

Abstract

Conflict of interest statement

Figures

Update of

Similar articles

Cited by

References

References to studies included in this review

References to studies excluded from this review

References to ongoing studies

Additional references

References to other published versions of this review

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical

Update in

Abstract

Conflict of interest statement

Figures

Update of

Similar articles

Cited by

References

References to studies included in this review

References to studies excluded from this review

References to ongoing studies

Additional references

References to other published versions of this review

Publication types

MeSH terms

Related information

LinkOut - more resources

Full Text Sources

Other Literature Sources

Medical