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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 4  |  Page : 1276-1280

Study of placental laterality with uterine artery Doppler in the prediction of preeclampsia


1 Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Obstetrics and Gynecology, Ministry of Health, El-Bagour Hospital, Menoufia, Egypt

Date of Submission16-Apr-2020
Date of Decision15-May-2020
Date of Acceptance17-Jun-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Ahmed E Nasser
MBBCh, El-Bagour, Menoufia 32717
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_133_20

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  Abstract 


Objective
To demonst rate if placental laterality combined with uterine artery Doppler can be used as a predictor for the development of preeclampsia.
Background
The uteroplacental blood flow may be deficient in cases with lateral placenta, and this may facilitate development of preeclampsia. Placenta is considered lateral when 75% or more of the placental mass is located at one side of the midline of uterine cavity. Uterine artery Doppler was done to all cases to find out high resistance index and abnormal protodiastolic notch in Doppler waveform.
Patients and methods
Ultrasonography was done for all participants at 18–22 weeks of pregnancy to determine the placenta location. Uterine artery Doppler was done for all cases at 18–24 weeks of gestation to find out the presence of protodiastolic notch and high resistance index.
Results
Of 73 cases with lateral placenta and high uterine artery resistance index, 56 (76.7%) cases developed preeclampsia (P = 0.026). Moreover, among 77 cases with lateral and presented protodiastolic notch, 57 (74%) cases developed preeclampsia (P = 0.050).
Conclusion
The risk of developing preeclampsia is significantly increased when lateral placentas are associated with uterine artery Doppler abnormality.

Keywords: Doppler, laterality, placenta, prediction, preeclampsia, uterine artery


How to cite this article:
Abd El-Aal NK, El Kelany OA, Mahmoud HS, Salama HF, Nasser AE. Study of placental laterality with uterine artery Doppler in the prediction of preeclampsia. Menoufia Med J 2020;33:1276-80

How to cite this URL:
Abd El-Aal NK, El Kelany OA, Mahmoud HS, Salama HF, Nasser AE. Study of placental laterality with uterine artery Doppler in the prediction of preeclampsia. Menoufia Med J [serial online] 2020 [cited 2021 Apr 19];33:1276-80. Available from: http://www.mmj.eg.net/text.asp?2020/33/4/1276/304482




  Introduction Top


Preeclampsia is a complex clinical disorder affecting multiple organ systems and still remains the main cause of maternal and perinatal mortality and morbidity, so there are continuous trials to detect the best predictive and preventive methods[1]. The pathogenesis of preeclampsia is supposed to be multifactorial, for example, abnormal placental implantation, maternal immunological intolerance, environmental, nutritional, and genetic factors, but it remains to be a subject of more research[2]. Recent research showed that the development of preeclampsia is caused by presence of placenta rather than the fetus[3]. Many tests are used to predict developing preeclampsia such as the cold pressor test, the isometric hand grip exercise, the roll over test, and the measurement of urinary calcium or plasma fibronectin based on the presence of pathophysiological and biochemical changes that occur before developing the disease[4]. There is a relation between placental location and uterine artery resistance and adverse outcomes such as preeclampsia and intrauterine growth restriction[5]. In lateral placenta, the uterine artery close to the placenta has lower resistance than the opposite one, and the uteroplacental blood flow required is supplied by one of the uterine arteries with small contribution from the other uterine artery through the collateral circulation, but in central placenta, both uterine arteries have the same resistance and the uteroplacental blood flow required is supplied by equal contribution from both uterine arteries. The degree of collateral circulation is different from one woman to another, and deficient contribution may facilitate the development of preeclampsia, intrauterine growth restriction, or both[2]. The aim of this study was to demonstrate if placental laterality combined with abnormal uterine artery Doppler waveform can be used as a predictor for the development of preeclampsia.


  Patients and methods Top


This was a prospective cohort study that was carried out in the Department of Obstetrics and Gynecology at El-Bagour General Hospital, El Bagour City, El-Menoufia governorate, Egypt, from April 2018 to April 2019, after approval from Faculty of Medicine ethics committee for human research. Informed consent was taken from all participants after explanation of the nature and scope of the study.

Pregnant between 18 and 22 weeks of pregnancy, single fetus, intact membrane, normotensive at the time of joining the study, and without any high-risk factor were included in the study. However, cases with chronic or essential hypertension, thyrotoxicosis, renal disease, diabetes mellitus, severe anemia, connective tissue disorder, positive lupus anticoagulant, anticardiolipin antibodies, Rh incompatibility, twin pregnancy, and history of smoking were excluded from the study. The gestational age was determined according to last menstrual period and confirmed by first trimester ultrasound examination, or by ultrasound alone if the monographic determination of gestational age differed from the menstrual dating by more than 1 week for every case. Ultrasound examination was performed to determine placental location at 18–22 weeks by Siemens (Brussels, Belgium )×300 Acuson premium edition device equipped with a 3–5-MHz transabdominal two-dimensional convex transducer. The placenta was classified as central when it was equally distributed between the right and left side of uterus, irrespective of anterior, posterior, or fundal position. When 75% or more of the placental mass was located at one side of the midline of uterine cavity, it is considered lateral placenta[2]. Color Doppler was done for all cases at 18–24 weeks of gestation to find out the uterine artery resistance index and abnormal notching in Doppler waveform. Doppler insonation of the uterine artery is at the level of its apparent crossover with the external iliac artery. Using this method, the probe is positioned ~2–3 cm inside the iliac crests and then directed toward the pelvis and the lateral side of the uterus. Color flow Doppler is used to identify each uterine artery. Pulsed wave Doppler is applied ~1 cm above the point at which the uterine artery crosses over the external iliac artery. This ensures that Doppler velocities are obtained from the main uterine artery trunk. Uterine artery resistance index of more than 0.56 and presence of protodiastolic notch in the placental ipsilateral side in uterine artery were taken as significant[6]. We noticed that when uterine artery resistance index is more than or equal to 0.56 in the placental ipsilateral side in the uterine artery, protodiastolic notch appears in Doppler waveform, and these cases developed preeclampsia later on pregnancy. When Rhode Island (RI) was considered abnormal when it ≥ 0.56, there was no changes in uterine artery Doppler waveform. Our findings were similar to Yousuf et al. (2016), who worked on RI more than or equal to (6). In cases of lateral placenta, RI was taken from the uterine artery of the same side of the placenta. However, in case of central placenta, it was taken from any side, as both uterine arteries have the same resistance, and the uteroplacental blood flow required is supplied by an equal contribution from both uterine arteries. All participants were followed till 40 weeks of gestation for occurrence of signs and symptoms of preeclampsia as regarding American College of Obstetrics and Gynecology. Women who delivered before 40 weeks but after 37 weeks were also included in the final analysis irrespective of development of preeclampsia. Cases who delivered before 37 weeks but developed preeclampsia at any time were also included in the final analysis[7].

Statistical analysis

Data were collected, tabulated, and statistically analyzed using Statistical Package for Social Science program version 20 (SPSS Inc., Chicago, Illinois, USA). χ2 test was used to measure association between qualitative variables. Fisher exact test was used for 2 × 2 qualitative variables when more than 25% of the cells have expected count less than five. Student t test was used to compare mean and SD of two sets of quantitative normally distributed data, whereas Mann–Whitney test was used when these data were not normally distributed. Sample size was calculated according to previous studies. The prevalence of lateral placenta accounted for 24.5%. To achieve 80% power to detect that difference at 5% level of significance, it was estimated that 250 pregnant women were required.


  Results Top


The mean age of included women was 26.12 ± 4.94, the mean BMI was 32.364 ± 5.18, the mean systolic blood pressure at time of examination was 105.36 ± 11.757, the mean diastolic blood pressure was 67.28 ± 8.77, and the mean date of delivery was 38.59 ± 0.937 [Table 1]. According to the relation between placental location combined with uterine artery Doppler, presence of protodiastolic notch, and development of preeclampsia. We observed that among cases with lateral placenta and normal uterine artery Doppler, only 20 (34.5%) cases developed preeclampsia, whereas of cases with lateral placenta and abnormal uterine artery Doppler, 56 (76.7%) cases developed preeclampsia (P = 0.026). We also found that among cases with lateral placenta with absent protodiastolic notch in uterine artery Doppler waveform, only 19 (35.2%) cases developed preeclampsia, but when this notch was presented, 57 (74%) cases developed preeclampsia (P = 0.050) [Table 2]. Doppler of uterine artery at cutoff point of 0.575 has 64.47% sensitivity, 69.09% specificity, 15.35 positive predictive value, 95.72 negative predictive value, with area under the curve = 0.70 and 68.72% accuracy in prediction of preeclampsia (P = 0.001) [Table 3],[Table 4],[Table 5]. The area under a receiver operating characteristic curve quantifies the overall ability of the Doppler of uterine artery to predict preeclampsia. Area under the curve of Doppler of uterine artery was 0.70, with P value less than 0.001 [Figure 1].
Table 1: Demographic data of the patients included in the study

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Table 2: Relation between uterine artery

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Table 3: Sensitivity and specificity of Doppler of uterine artery at cut of point (0.575)

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Table 4: Relation between combined uterine artery Doppler with protodiastolic notch, placental location, and development of preeclampsia

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Table 5: Tests of normality for preeclampsia and uterine artery Doppler

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Figure 1: Receiver operating characteristic curve for Doppler of uterine artery in prediction of preeclampsia.

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  Discussion Top


This prospective cohort study included 250 of pregnant women who have been subjected to antenatal ultrasonographic examination for placental localization combined with uterine artery Doppler at 18–24 weeks of gestation, with the aim of finding whether they can be used in the prediction of preeclampsia. Among 250 women who were included in this study, 131 (52.4%) women were with lateral placentas and 119 (47.6%) women were with central placentas. Of 131woman with lateral placentas, 76 (58%) cases developed preeclampsia, and of 119 women with central placenta, just 52 (43.7%) developed preeclampsia (P < 0.05). Our findings were in agreement with Ghadei and Mohanty[8], who observed that of the total 300 women, 168 (56%) had laterally located placenta, and of them, 112 (66.6%) developed preeclampsia, whereas the remaining 112 (44%) had centrally located placenta, and of them, 48 (36.3%) developed preeclampsia (P = 0.00002). Yousuf et al.[6] and Kakkar et al.[9] observed in their study that there was an increase in the incidence of preeclampsia in lateral placentas. On the contrary, our findings were different from Antsaklis et al.[10], who noticed that there was no increase in the incidence of preeclampsia in lateral placentas. Moreover, Magann et al.[11] reported in their study, which included 3336 patients from Western Australia and Mississippi, that there was no association with preeclampsia, FGR, preterm birth, and other adverse obstetric outcomes, and finally, Devarajan et al.,[12] did not find an increased incidence of preeclampsia in their lateral placenta group. We also noticed that among 133 women with presented protodiastolic notch in uterine artery Doppler waveform, 90 (67.7%) cases developed preeclampsia later on pregnancy, whereas of 117 women with absent notch, only 38 (32.3%) cases developed preeclampsia (P < 0.05). This finding was similar to other researchers, including Nagar et al.[13], Pagani et al.[14], and Ventura et al.[15], who found a significant association of abnormal antenatal Doppler abnormalities with development of preeclampsia. On the contrary, it was different from Pedroso et al.[16], who concluded in their study done that screening of preeclampsia by uterine artery Doppler alone has less sensitivity and should be combined with other methods to be more accurate. During this study, we found that 34.5% of cases with lateral placenta and normal uterine artery Doppler developed preeclampsia in comparison with 76.7% of cases with lateral placenta and abnormal uterine artery Doppler developed preeclampsia (P < 0.05). We noticed the incidence of preeclampsia was high among those with central placental location with normal Doppler, and this finding was in accordance with Sandhya et al.[8], who had also a higher incidence of preeclampsia among this group. Regarding protodiastolic notch in uterine artery Doppler waveform, we noticed that 35.2% of cases with lateral placenta with absent notch developed preeclampsia, but when this notch was presented, 74% cases developed preeclampsia (P < 0.05). Jani et al.[17] in their study in 2015 reported similar findings. They observed that of 400 cases enrolled, 80 (20%) cases had lateral placentas on ultrasound examination done at 18–24 weeks of gestation. Of the 80 women with laterally located placenta, 28 (35%) developed preeclampsia, which was statistically significant. A total of 26 participants had raised uterine artery resistance, and of them, 22 (84%) developed preeclampsia; of the remaining 54 women, only six (11%) developed preeclampsia (P = 0.001). Receiver operating characteristic curves were produced in an attempt to show the ability of uterine artery Doppler in laterally located placenta to predict the occurrence of preeclampsia with accuracy of 68.72% (P = 0.001).


  Conclusion Top


In this study, we noticed that pregnant women with lateral placenta combined with uterine artery Doppler abnormality (high RI =0.56 and presence of protodiastolic notch) can be considered as a predictor for the development of preeclampsia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ghadei R, Mohanty GS. Placental laterality as a predictor of preeclampsia. J Evol Med Dent Sci 2017; 6:2885–2888.  Back to cited text no. 8
    
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Ventura W, De Paco Matallana C, Prieto-Sanchez MT, Macizo MI, Pertegal M, Nieto A, Delgado JL. Uterine and umbilical artery Doppler at 28 weeks for predicting adverse pregnancy outcomes in women with abnormal uterine artery Doppler findings in the early second trimester. Prenat Diagn 2015; 35:294–298.  Back to cited text no. 15
    
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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