Open Journal of Obstetrics and Gynecology, 2012, 2, 197-201 OJOG Published Online September 2012 (
Doppler measurements in fetal descending aorta and
umbilical artery can predict borderline oxygenation
in pre-eclampsia and HELLP syndrome
Susanne E. Gruessner1,2*, Charles O. A. Omwandho3, Corinna Peter4
1Department of Obstetrics, Gynecology and Reproductive Medicine, Hannover Medical School, Hannover, Germany
2Department of Obstetrics and Gynecology, Justus-Liebig-University of Giessen, Giessen, Germany
3Department of Biochemistry, University of Nairobi, Nairobi, Kenya
4Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Hannover, Germany
Email: *, *
Received 27 July 2012; revised 31 August 2012; accepted 11 September 2012
Objective: To determine diagnostic utility of Doppler
measurements in fetal descending aorta and umbilical
arteries in predicting intrauterine growth retarded
(IUGR) fetuses at risk in pregnancies complicated by
pre-eclampsia and/or HELLP syndrome. Methods:
Doppler measurements were taken in fetal descend-
ing aorta and umbilical arteries of 53 patients with
pre-eclampsia, 10 of whom had HELLP syndrome
using fetometry (ACUSON 128XP/10, 3.5 MHz probe).
These values were compared with those of 44 appro-
priate-for-gestational age singleton pregnancies (AGA).
Doppler Indices (Resistance Index (RI), Systolic/Dia-
stolic (S/D) ratio) and end-diastolic flows were related
to fetal heart rate (FHR) during contraction stress
test, to cord blood parameters (pH, Base Excess) and
to Apgar Scores. Results: In contrast to AGA fetuses,
IUGR fetuses ha d de c reased end-diastolic flow and an
increase of Doppler Indices significantly earlier in the
descending aorta (p < 0.05), compared to umbilical
artery. Increased RI’s, S/D ratios and a decrease of
end-diastolic flow in fetal aorta were significantly
correlated to frequency of FHR decelerations during
contraction stress tests, pH, Base Excess (p < 0.01)
and Apgar Scores in IUGR fetuses. Conclusion: A
decrease in end-diastolic flow paralleled with an in-
crease in Doppler indices in fetal descending aorta
reflect oxygen deprivation in IUGR fetuses during
pre-eclamptic pregnancies with or without HELLP
syndrome. While ductus venous and umbilical artery
are more frequently used nowadays to determine fetal
oxygen deprivation, Doppler measurements in fetal
descending aorta provide additional information for
early detection of fetuses at risk for IUGR in pregnan-
cies complicated with pre-eclampsia and/or HELLP
Keywords: Pre-Eclampsia; IUGR; Doppler Velocimetry;
Fetal Descending Aorta
In pre-eclamptic pregnancies complicated with HELLP
syndrome, a severe form of pre-eclampsia, the fetus is
deprived of oxygen. Consequential there is redistribution
of organ blood flow and an increase of resistance in fetal
vessels leading to intrauterine growth retardation (IUGR)
or fetal death [1]. Clinical diagnosis is difficult but usu-
ally associated with abdominal pain or vomiting during
third trimester of pregnancy, hemolysis, increased serum
bilirubin (>1.2 mg/dL), hepatic dysfunction demon-
strated by increased transaminase activities (LDH > 600
IU/L), and thrombocytopenia (<100.000/µl) [2]. Progno-
sis is poorer when pre-eclampsia develops earlier in pre-
gnancy [1]. Although the descending aortic blood flow
represents approximately 60% of fetal cardiac output,
cardiotocography, serial ultrasound measurements, and
Doppler flow velocimetry of umbilical artery and fetal
middle cerebral arteries have commonly been used to
assess fetal well-being and to guide management of preg-
nancies complicated with pre-eclampsia with or without
HELLP syndrome [3-8]. None of these studies have
compared diagnostic utility of fetal descending aorta and/
or umbilical artery with late fetal heart rate (FHR) dece-
lerations following a contraction stress test. The purpose
of this study was to investigate 1) whether or not Dop-
pler flow measurements of descending aorta and/or um-
bilical artery can sufficiently predict blood flow redistri-
bution in growth retarded (IUGR) compared to appropri-
ate for gestational age (AGA) fetuses, 2) if the decrease
*Corresponding author.
S. E. Gruessner et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 197-201
in end-diastolic-flow (Vmin) in descending aorta occurs
parallel to late fetal heart rate decelerations during fetal
stress, 3) correlation between Resistance Index (RI) and
S/D ratio of fetal descending aorta and/or umbilical ar-
tery with the decrease of stress test score (CTG) of FHR
and 4) whether or not the RI of fetal descending aorta
and/or umbilical artery correlates with birth weight, cord
blood gas parameters (pH, pO2, Base excess) and Apgar
The study population consisted of 53 patients, 43 of
whom had pre-eclampsia and 10 with pre-eclampsia
complicated with HELLP syndrome. The control group
consisted of 44 patients with biometric data of AGA fe-
tuses. Pre-eclampsia was defined by the triad of elevated
maternal blood pressure (systolic blood pressure > 150
mmHg and/or diastolic pressure > 90 mmHg on 2 occa-
sions, 6 hours apart), proteinuria (>300 mg per 24 hours)
and generalized maternal edema. HELLP syndrome was
defined by hemolysis (bilirubin > 1.2 mg/dl, hemor-
rhage, anemia, elevated liver enzymes (lactate dehydro-
genase, LDH > 600 U/l, alanine aminotransferase, ALT >
47 U/l, aspartate aminotransferase, AST > 56 U/l) and
low platelet counts (<100.000/µl).
A pulsed Doppler ACUSON 128 XP/10 with a 3.5
MHz probe was used for fetometry. IUGR was based on
assessment of birth weight < 10th percentile for gesta-
tional age, according to percentile charts for singleton
fetuses, developed by Hohenauer [9].
End-diastolic-flow velocity (Vmin) and Doppler indices
(RI, S/D ratio) of fetal descending aorta and umbilical
artery were related to fetal heart rate pattern during con-
traction stress test. In order to provide information on
uterine reserve capacity and predict borderline oxygena-
tion following fetal heart reactions, uterine contractions
were either spontaneous or induced by inhalation or in-
fusion of oxytocin in cases where contractions were not
registered in pregnancies with IUGR fetuses. Only the
last Doppler measurements within 0 - 5 days before birth
were used for analysis. Fetal heart rate score (CTG score)
was carried out by evaluating baseline frequency, os-
cillations and accelerations, long term alterations and
decelerations. The score was related to uterine contrac-
tions with ten points best and zero points poorest result.
Doppler spectral recordings were taken from placental
insertion of umbilical artery and fetal descending aorta.
Mothers were either in a supine position or at a slight left
lateral tilt during these investigations. Maximum systolic
(Vmax) and end-diastolic (Vmin) velocities were measured
as frequencies (Hz) using calipers to obtain three repro-
ducible recorded waveforms. Patients with pre-eclampsia
and/or HELLP syndrome were delivered by caesarean
section, while the control group had vaginal delivery. For
statistical analysis, correlation coefficient and linear re-
gression models were calculated with a p value < 0.05
indicating statistical significance. Qualitative variables
were compared by Fisher’s exact and Chi square tests
while quantitative variables were compared using the
Wilcoxon 2 sample test. Ethical clearance was obtained
from the relevant office and experiments conducted in
accordance with the Helsinki declaration of 1982 re-
garding use of human subjects.
Median gestational age was 32 weeks vs. 29 weeks for
pre-eclamptic patients and those with HELLP syndrome
respectively compared to 40 weeks in the control group
(Table 1). The median end-diastolic velocity of fetal de-
scending aorta was significantly decreased (0Hz) in both
study groups (Wilcoxon 2 sample test: p < 0.0001; Chi2
test: p < 0.0001) compared to control group (355 Hz).
End-diastolic velocity of umbilical artery was 175 Hz in
the pre-eclamptic group, 0 Hz in HELLP, and 450 Hz in
the control groups respectively (Table 1 ). Differences in
end-diastolic flow velocity of umbilical artery were sig-
Table 1. Flow velocities vs. gestational age and birth weight.
Fetal descending aorta Umbilical artery
Number of Patients
Gestational Age [wk]
Median (min-max)
Birth Weights [g]
Median (min-max)
Vmax [Hz]
Median (min-max)
Vmin [Hz]
Median (min-max)
Vmax [Hz]
Median (min-max)
Vmin [Hz]
Median (min-max)
Pre-Eclampsia (43) 32 (27 - 40) 1130 (510 - 2750)1200 (675 - 1920)0 (0 - 250) 925 (475 - 1770) 175 (0 - 440)
HELLP (10) 29 (27 - 39) 940 (510 - 2500) 1188 (870 - 1850)0 (0 - 200) 925 (600 - 1350) 0 (0 - 250)
Control (44) 40 (32 - 41) 3430 (1780 - 4100)1350 (900 - 2300)355 (190 - 760)1125 (700 - 2320) 450 (245 - 890)
p HELLP vs. Control <0.0001 <0.0001 0.008 < 0.0001 0.16 <0.0001
p Pre-Eclampsia
vs. Control <0.0001 <0.0001 0.001 < 0.0001 <0.0001 <0.0001
vs. Pre-Eclampsia 0.132 0.24 0.546 0.615 0.633 0.055
Copyright © 2012 SciRes. OPEN ACCESS
S. E. Gruessner et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 197-201 199
nificant for both study groups (Wilcoxon 2 sample test: p
= 0.0001; Chi2 test: p = 0.0001) compared to controls.
End-diastolic flow velocity was significantly lower in the
descending aorta for patients with HELLP syndrome (Rp
= 0.7, p < 0.0001, RHELLP = 0.93, p < 0.0001) and in the
control group (Rc = 0.49, p = 0.001) compared to um-
bilical artery (Figure 1). The decrease in fetal heart rate
score was paralleled with loss of end-diastolic flow ve-
locity in the fetal descending aorta (Rp = 0.46, p = 0.002;
RHELLP = 0.56, p = 0.092) (Figure 2), rather than in the
umbilical artery (Rp = 0.41, p = 0.006; RHELLP = 0.44, p =
0.20). CTG score was 4 points in pre-eclamptic patients;
3.5 in patients with HELLP syndrome compared to 10
points in controls. Differences between CTG scores of
0200400 600 800
Umbilical artery [Hz]
Aorta [Hz]
Preeclam psia
= 0.77 p < 0.0001
= 0.93 p < 0.0001
= 0.49 p = 0.001
Figure 1. End-diastolic flow velocities (Vmin) in fetal
descending aorta vs. umbilical artery.
CTG - score
Aorta [Hz]
Pre eclampsia
Co ntrol
Pre-eclamps ia
Co ntrol
RPre-eclampsia = 0.46 p = 0.002
RHellp = 0.56 p = 0.092
RControl = 0.32 p = 0.03
Figure 2. End-diastolic flow velocities (Vmin) in fetal
descending aorta vs. CTG score.
pre-eclamptic patients with HELLP syndrome was sig-
nificant, compared to control group (Wilcoxon 2 sample
test: p < 0.0001; Chi2 test: p < 0.0001). Median birth
weight was 3430 g for the control group, 1130 g in pre-
eclamptic group and 940 g in HELLP syndrome group.
An increase of RI in fetal descending aorta (R = 0.45, p
= 0.002), rather than umbilical artery (R = 0.34, p =
0.02) correlated with deterioration of CTG stress test
scores in the study groups. There was no correlation be-
tween RI and CTG score in both vessels (RcAorta = 0.29;
p = 0.053; RcUmbilical artery = 0.21, p = 0.17 for the control
group). A significant correlation existed in the S/D ratios
of aorta (R = 0.43, p = 0.004) and umbilical artery (R =
0.33, p = 0.03) with deterioration of CTG stress test
score in the pre-eclamptic group.
Resistance index of >80% in fetal descending aorta
and late FHR decelerations were obtained in 52 of the 53
patients (98%), whereas only 31 of 53 (58%) patients
had RI of >80% in the umbilical artery together with late
FHR decelerations. However, of the 53 patients, 11 (21%)
had RI of <70% in umbilical artery although late FHR
decelerations were detectable in 10 of these 11 patients
(91%). For the groups with pre-eclampsia alone or with
HELLP syndrome, there was no correlation between the
RI or S/D ratio in the fetal descending aorta or umbilical
artery and base excess. There was no correlation between
RI or S/D ratio of the aorta/umbilical artery and pH value,
pO2 and Apgar Score after 1, 5 and 10 minutes (p > 0.05)
in patients with HELLP syndrome and controls. However,
there was a significant increase in RI and S/D ratios
between descending aorta (RIp:R = 0.67 p = 0.0001;
RIHellp:R = 0.84 p = 0.002; S/Dp:R = 0.65 p = 0.0001;
S/DHellp:R = 0.87 p = 0.006) and umbilical artery (RIc:R
= 0.44 p = 0.003; S/Dc:R = 0.46 p = 0.002) in both
pre-eclamptic patients with and without HELLP syn-
Pre-eclampsia is associated with inadequate invasion of
trophoblast leading to placental ischemia due to insuffi-
ciently dilated uterine spiral arteries [1]. This leads to
hypertension, involving multiple organs. Treatment re-
quires premature termination of pregnancy, either by
caesarean section or vaginal delivery if cervical condi-
tions are optimal. Many studies have associated pre-
eclampsia with increased perinatal (25%) and maternal
(3% - 5%) morbidity and mortality [10-13], decreased
neonatal birth weights and higher incidence of premature
delivery [12,14,15]. The low birth rates recorded in our
study for pre-eclamptic patients with or without HELLP
syndrome are thus in agreement with previous reports
12,14,15]. In this study, IUGR was associated with a
decrease in end-diastolic flow velocities in the descend-
Copyright © 2012 SciRes. OPEN ACCESS
S. E. Gruessner et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 197-201
ing aorta before changes in umbilical artery were de-
tected. This decrease correlated with deterioration of
CTG stress test score. Frequency of late FHR decelera-
tions negatively correlated with an increase in RI and
S/D ratio of the descending aorta rather than of umbilical
artery. An increase in the RI and S/D ratio of the de-
scending aorta negatively correlated with Base excess.
No correlation was found between RI and S/D ratio of
descending aorta, umbilical artery, pH and Apgar Scores.
These results confirm that Doppler measurements of fetal
descending aorta can give early warning of fetal boder-
line oxygenation. Although ductus venous, an index
vessel for cardiac insufficiency is frequently used nowa-
days to monitor fetal distress, there is evidence that
IUGR infants with severe changes of fetal blood in utero
had impaired postnatal development of neurological
[16,17] and intellectual function [18]. These observations
suggest that it may be advantageous to deliver IUGR
fetuses before advent of venous flow impairment and
deterioration of fetal heart rate [19]. According to Illanes
and Soothill [20], delivery of a fetus that is well but a
little less mature is likely to be better than one who is
older but sick. Thus, management approaches that wait
for fetal coma and renal failure as indicated by flat CTGs
and severe oligohydramnios to decide time of delivery
may not be appropriate. In one study, Brodszki et al. [21]
reported that 23 adolescents with history of IUGR and
abnormal fetal aortic bloodflow (n = 23) due to placental
insufficiency had impaired vascular growth comprising
of smaller aortic dimensions and higher resting heart
rates, suggesting that fetal descending aorta may play a
critical role in pre- and postnatal vascular development.
According to Mandruzzato et al. [22] fetal descending
aorta is suitable for blood flow velocity measurements
because it provides 1) a straight course with good visu-
alization from thoracic to abdominal part 2) great reli-
ability and reproducibility of sample volume and angle
estimation and 3) a likelihood that aortic thoracic blood
flow velocity waveform reflects the hemodynamic state
of a large portion of the fetal circulation (including pla-
cental perfusion, peripheral perfusion, and cardiac out-
put). We used in addition to umbilical artery, a combina-
tion of Doppler measurements in fetal descending aorta
and CTG stress test in order to secure delivery before
onset of cardiac insufficiency that would have been de-
tected by taking Doppler measurements of the ductus
Although a number of studies have predominantly used
ductus venous and umbilical artery as indices of fetal
distress, data presented in this report demonstrate that
Doppler measurements in the fetal descending aorta
provide additional diagnostic value in detecting fetuses at
risk for IUGR in pre-eclamptic pregnancies with or with-
out HELLP syndrome.
[1] Kang, A. and Struben, H. (2008) Pre-eclampsia screening
in first and second trimester. Therapeutische Umschau,
65, 663-666. doi:10.1024/0040-5930.65.11.663
[2] Beucher, G., Simonet, T. and Dreyfus, M. (2008) Man-
agement of HELLP syndrome. Gynecology Obstetrics
Fertility, 36, 1175-1190.
[3] Bush, K.D., O’Brien J.M., and Barton, J.R. (2001) The
utility of umbilical artery Doppler investigation in women
with the HELLP (hemolysis, elevated liver enzymes and
low platelets) syndrome. American Journal of Obstetrics
& Gynecology, 184, 1087-1089.
[4] Baschat, A.A., Gembruch, U., Weiner, C.P. and Harman,
C.R. (2003) Qualitative venous Doppler waveform analy-
sis improves prediction of critical perinatal outcomes in
premature growth-restricted fetuses. Ultrasound in Ob-
stetrics & Gynecology, 22, 240-245. doi:10.1002/uog.149
[5] Sterne, G., Shields, L.E. and Dubinsky, T.J. (2001) Ab-
normal fetal cerebral and umbilical Doppler measure-
ments in fetuses with intrauterine growth restriction pre-
dicts the severity of perinatal morbidity. Journal of
Clinical Ultrasound, 29, 146-151.
[6] Johnson, P., Stojikovic, T. and Sarkar, P. (2001) Middle
cerebral artery Doppler in severe intrauterine growth re-
striction. Ultrasound in Obstetrics & Gynecology, 17,
416-420. doi:10.1046/j.1469-0705.2001.00404.x
[7] Muller, T., Nanan, R., Rehn, M., Krieten, P. and Dietl, J.
(2002) Arterial and ductus venosus Doppler in fetuses
with absent or reverse end-diastolic flow in the umbilical
artery: Correlation with short-term perinatal outcome.
Acta Obstetricia et Gynecologica Scandinavica, 81, 860-
866. doi:10.1034/j.1600-0412.2002.810911.x
[8] Bilardo, C.M., Wolf, H., Stigter, R.H., Ville, Y., Baez, E.,
Visser, G.H.A. and Hecher, K. (2004) Relationship be-
tween monitoring parameters and perinatal outcome in
severe, early intrauterine growth restriction. Ultrasound
in Obstetrics & Gynecology, 23, 119-125.
[9] Hohenauer, L. (1980) Intrauterine wachstumskurven fuer
den deutschen sprachraum. Z Geburtsh. u . Perinat, 184,
[10] Vigil De-Gracia, P. (2009) Maternal deaths due to eclam-
psia and HELLP syndrome. International Journal of Gy-
necology & Obstetrics, 104, 90-94.
[11] Sibai, B.M., Ramadan, M.K., Usta, I., Salama, M.,
Mercer, B.M. and Friedman, S.A. (1993) Maternal mor-
bidity and mortality in 442 pregnancies with hemolysis,
elevated liver enzymes, and low platelets (HELLP syn-
drome). American Journal of Obstetrics & Gynecology,
169, 1000-1006.
Copyright © 2012 SciRes. OPEN ACCESS
S. E. Gruessner et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 197-201
Copyright © 2012 SciRes.
[12] Martin, J.N. Jr, Perry, K.G. Jr, Miles, J.F. Jr, Blake, P.G.,
Magann, E.F., Roberts, W.E. and Martin, R.W. (1993)
The interrelationship of eclampsia, HELLP syndrome,
and prematurity: Cofactors for significant maternal and
perinatal risk. British Journal of Obstetrics and Gynae-
cology, 100, 1095-1100.
[13] Rath, W., Faridi, A. and Dudenhausen, J.W. (2000)
HELLP syndrome. Journal of Perinatal Medicine, 28,
249-260. doi:10.1515/JPM.2000.033
[14] Joern, H. and Rath, W. (1998) Comparison of Doppler
sonographic examinations of the umbilical and uterine
arteries in high-risk pregnancies. Fetal Diagnosis and
Therapy, 13, 150-153. doi:10.1159/000020827
[15] Joern, H., Funk, A. and Rath, W. (1999) Doppler sono-
graphic findings for hypertension in pregnancy and
HELLP syndrome. Journal of Perinatal Medicine, 27,
388-394. doi:10.1515/JPM.1999.053
[16] Ley, D., Laurin, J., Bjerre, I. and Marsal, K. (1996) Ab-
normal fetal aortic velocity waveform and minor neuro-
logical dysfunction at 7 years of age. Ultrasound in Ob-
stetrics & Gynecology, 8, 152-159.
[17] Fouron, J.C., Gosselin, J., Amiel-Tison, C., Infante-Ri-
vard, C., Fouron, C., Skoll, A. and Veilleux, A. (2001)
Correlation between prenatal velocity waveforms in the
aortic isthmus and neurodevelopmental outcome between
the ages of 2 and 4 years. American Journal of Obstetrics
& Gynecology, 184, 630-636.
[18] Ley, D., Tideman, E., Laurin, J., Bierre, I. and Marsal, K.
(1996) Abnormal fetal aortic velocity waveform and in-
tellectual function at 7 years of age. Ultrasound in Ob-
stetrics & Gynecology, 8, 160-165.
[19] Marsal, K. (2002) Intrauterine growth restriction. Current
Opinion in Obstetrics and Gynecology, 14, 127-135.
[20] Illanes, S. and Soothill, P. (2004) Management of fetal
growth restriction. Seminars in Neonatology, 9, 395-401.
[21] Brodszki, J., Lanne, T., Marsal, K. and Ley, D. (2005)
Impaired vascular growth in late adolescence after in-
trauterine growth restriction. Circulation, 11 1, 2623-2628.
[22] Mandruzzato, G.P., Meir, Y.J., Maso, G., Conoscenti, G.
and Rustico, M.A. (2003) Monitoring the IUGR fetus.
Journal of Perinatal Medicine, 31, 399-407.