Vol.2, No.9, 554-561 (2013) Case Reports in Clinical Medicine
Umbilical artery doppler flow patterns in high-risk
pregnancy and foetal outcome in Mulago hospital
P. Komuhangi1*, R. K. Byanyima2, E.Kiguli-Malwadde3, C. Nakisige4
1ECUREI, Mengo Hospital, Kampala, Uganda;
*Corresponding Author: patriciakomuhangi@yahoo.com
2Radiology Department, Mulago Hospital, Kampala, Uganda
3African Centre for Global Health and Social Transformation (ACHEST), Kampala, Uganda
4Department of Obstetrics and Gynaecology, Mulago Hospital, Kampala, Uganda
Received 21 January 2013; revised 20 February 2013; accepted 18 March 2013
Copyright © 2013 P. Komuhangi et al. This is an open access article distributed under the Creative Commons Attribution License,
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Objective: To demonstrate the flow patterns and
factors associated with adverse foetal outcome
in high-risk pregnancy at Mulago Hospital using
Doppler ultrasound of the foetal umbilical artery.
Design: Cross-sectional descriptive study. Set-
ting: Mulago National Referral Hospit al, Kampala
Uganda. Study Subjects: One hundred and ninety-
two patients in a 4-month period (December
2008-April 2009). Results: Maternal age was 16
to 41 years. Twenty-one foetuses had abnormal
flow p atte rns (12 had redu ced end -diastolic flow,
8 had AEDF and 1 had RF). Prematurity was as-
sociated with abnormal flow patterns. 11 out of
12 foetuses with reduced end-diastolic flow sur-
vived. Of the foetuses with AEDF, 3 survived but
were admitted to the neonatal special care unit
while 5 died. One foetus had RF and was a still-
birth. Eighteen foetuses were delivered after an
obstetric intervention. Conclusions: 1) The pre-
valence of abnormal flow patterns is 10.9%. 2)
Abnormal flow patterns, low biophysical profile
score, premature delivery, low birth weight and
low Apgar score are related to adverse foetal
outcome. 3) A low biophysical profile score is
related to AEDF/RF. 4) Foetuses of low parity
mothers are more likely to have abnormal flow
p atterns. Recommendation: Umbilical artery Dop-
pler Biophysical profile scores should be done
in high-risk pregnancy.
Keywords: Doppler; Umbilical Artery
High-risk pregnancy constitutes conditions that pre-
dispose to placental insufficiency. These cause foetal
compromise and are detected early by combined ante-
partum surveillance methods saving infant lives as well
as reducing foetal disabilities [1].
High-risk pregnancy is a situation in which the mother
has a condition likely to cause an adverse effect on the
foetus. High-risk groups include women with: a previous
complicated pregnancy, insulin dependent diabetes con-
nective tissue diseases, phenylketonuria, age over 35
years, alcohol and drug dependence, maternal infections
such as rubella, cytomegalovirus and toxoplasmosis [2].
According to the Uganda Clinical Guidelines (2003), a
high-risk pregnancy is one with a risk of an adverse out-
come for the mother or baby [3]. The criteria for high-
risk pregnancy are extremes of reproductive age (below
18 or greater than 35 years), young primigravida, high
parity or short birth interval, large infants of 4 kilograms
or more, prematurity, low birth weight of less than 2.5
kilograms, obstructed and difficult labours, poor obstet-
ric history, history of reproductive tract surgery, genetic
or familial diseases, medical conditions such as diabetes,
cardiac or renal disease, hypertension, rhesus incompati-
bility, maternal disabilities, those with obstetric risks
such as multiple pregnancy, malpresentations and others,
antepartum haemorrhage, postpartum haemorrhage, deep
vein thrombosis, intrauterine growth retardation, prema-
ture rupture of membranes, post dates and cephalopelvic
disproportion [4].
Hypertension may cause abnormal flow patterns in the
umbilical artery and other foetal vessels. Diabetes pre-
disposes pregnant mothers to preeclampsia and eclamp-
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P. Komuhangi et al. / Case Reports in Clinical Medicine 2 (2013) 554-561 555
sia. Abnormal flow velocities may be seen in the um-
bilical and uterine arteries in foetal growth retardation
Doppler ultrasound besides other obstetric tests can
detect impeding foetal hypoxia [5]. Reversal of flow or
absent end-diastolic flow in the umbilical artery shows
foetal compromise [1]. Doppler ultrasound in high-risk
pregnancies improves a number of obstetric care out-
comes and appears promising in helping to reduce peri-
natal deaths [6]. The intrapartum stillbirths are 14 times
more in developing than developed countries [7].
The perinatal mortality rate in Uganda is 53 per 1000
live births, infant mortality 88 per 1000 live births and
neonatal mortality is 41% of all infant deaths [8,9]. In
Mulago Hospital, there are about 15 neonatal deaths per
1000 births [9] and the still birth rate is 23 per 1000
births [10]. High-risk pregnancy is associated with a high
rate of obstetric intervention in a bid to save the mother’s
and/or baby’s life.
Doppler ultrasound is available in Mulago Hospital,
therefore, it can be done in high-risk pregnancies to de-
tect foetal compromise and intervention, if necessarily
instituted to save infant lives. This study was aimed to
demonstrate the Doppler foetal umbilical artery flow
patterns and their relationship with the foetal outcome at
Mulago Hospital.
The study was carried out in Mulago National Referral
Informed consent was obtained from all the study par-
ticipants. The sample size was calculated using Kish and
Leslie’s formula [42] for cross-sectional studies and it
came to 202 participants. 192 (94%) patients were, how-
ever, recruited due to limited resources.
2.1. Inclusion Criteria
All high-risk pregnancy mothers of 28 weeks gesta-
tional age and above who attended antenatal clinic or
were admitted in the obstetric wards from December
2008 to April 2009.
2.2. Exclusion
Multiple pregnancy mothers and those in labour.
Real time ultrasound with a curvilinear 3.5 MHz probe
and Doppler was used. The umbilical arteries were iden-
tified by colour-flow mapping and one artery sampled at
random. With the Doppler power settings set as low as
possible, using a minimal wall filter, the Doppler meas-
urements were done away from the cord insertion of the
umbilical artery where the audible signal was highest (i.e.
where flow was maximum) [43,44]. The Doppler re-
cordings were made with the angle of insonation be-
tween the Doppler beam and direction of flow less than
30 degrees [45]. The mothers were told to hold their
breaths when recording the Doppler spectra [1]. The re-
sistance indices were calculated using the formula: sys-
tolic-diastolic flow/systolic flow. The biophysical profile
was done for each pregnancy.
One hundred and ninety-two patients were recruited.
Their age range was 16 to 41 years of age. Thirty-four
percent of the patients were in the 21 - 25 year age range.
The mean age of the patients was 23, the median age was
28.5 and the mode was 23 years.
One hundred and seventy-four (90%) of the mothers
had hypertension in pregnancy, 14 (7%) had IUGR
without hypertension while 8 had IUGR with hyperten-
sion and 4 (2%) had Diabetes Mellitus.
All the mothers were residing in the central region
around the city of Kampala.
3.1. Prevalence of Abnormal Umbilical
Artery Doppler Flow Patterns
The prevalence of abnormal flow patterns in Mulago
Hospital according to this study was 10.95% and these
included: reduced end-diastolic flow (6.25%), AEDF
(4.2%) and RF (0.5%).
All the foetuses with AEDF/RF were delivered pre-
maturely, 8 by obstetric intervention i.e. 4 by caesarian
section and 4 after induction of labour. This is statisti-
cally significant. P = 0.0004 OR 17.54 (1.98 - 155.4).
The majority of foetuses with AEDF and RF had low
birth weights (less than 2.5 kg); 5 of them weighed less
than 1.5 kg. Most were admitted to the neonatal special
care unit. This was a high rate of still/births among foe-
tuses with AEDF/RF. P =< 0.0001 OR 38.7 (6.61 - 226).
Of the twelve foetuses with reduced end diastolic flow,
8 (66.7%) were born prematurely but the most survived.
Nine of them (75%) had a good Biophysical profile score
and 8 (66.7%) had an Apgar score of 8 - 10.
Ten of the foetuses (83%) were delivered by obstetric
intervention, 6 by caesarian section and 4 by induction of
labour. The birth weights of the foetuses were <2.5 kg
for 7 of the foetuses and of these 2 were below 1.5 kg.
The foetuses with AEDF/RF were more at risk of
having an adverse outcome than the ones with normal
flow patterns. There were only 9 foetuses (5%) with ad-
verse outcomes among those with normal flow patterns.
Five of the 9 foetuses with AEDF/RF had a low bio-
physical profile score.
Nine of the 12 foetuses with reduced end-diastolic
flow (75%) had a good biophysical profile score of 8 to
A sub-analysis of the resistance indices of 150 patients
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P. Komuhangi et al. / Case Reports in Clinical Medicine 2 (2013) 554-561
was done. The resistance indices ranged from 0.21 to
0.88. Thirty-two of the 34 (94%) foetuses with high um-
bilical artery resistance indices were of hypertensive
Foetuses delivered at 28 - 36 weeks were 3 times more
likely than those delivered at 37 - 42 weeks to have had a
high umbilical artery resistance index. OR 3.17 (CI 1.40
- 7.17) P = 0.00. This is statistically significant. A big
proportion of the foetuses with high umbilical artery re-
sistance indices (88%) had an obstetric intervention and
of these 18 (53%) were delivered by caesarian section.
High resistance indices were not associated with poor
foetal outcome.
High umbilical artery resistance indices were not as-
sociated with a low biophysical profile score (8 - 10).
A cross-sectional descriptive study on the umbilical
artery Doppler flow patterns in high-risk pregnancy and
foetal outcome in Mulago Hospital which is in the city of
Kampala, Uganda was done.
Most of the study patients were in the age range of 21
- 25 years. This is because it is when most women have
their children in Uganda. It is just after the age of con-
sent (18 years). Many women leave school early so they
tend to start having children at an early age.
Eighty-four percent of the mothers were multiparous.
Pregnancy-induced hypertension, which most of the
mothers had has been reported to be common among
nulliparous women by some studies [45,46]. It is also
reported that PIH occurs in multiparous women because
of increased incidence of chronic hypertension with in-
creasing maternal age [4]. The fertility rate in Uganda is
one of the highest in the world (6.5 in 2007) [47] and
there is no government limit on how many children a
couple can have. The infant mortality rate is high and
most mothers want many children because of the belief
that if some children die, they can retain some. Since
Mulago Hospital is a national referral hospital, many
multiparous mothers also come because they are referred
from the peripheral units.
The prevalence of abnormal flow patterns in Mulago
Hospital according to this study was 10.95% with re-
duced end-diastolic flow (Figure 1) being 6.25%, AEDF
(Figure 2) 4.2% and RF (Figure 3) 0.5%. This is almost
the same as reported in literature i.e. is 5% - 8% for
AEDF and 0.5% for RF [1] although it was a little bit
lower. This could be that some of the mothers whose
foetuses had abnormal flow patterns were missed since
some of them deliver from home or the smaller health
units with no Doppler ultrasound machines. A total of 21
foetuses had abnormal flow patterns (12 with reduced
end-diastolic f1ow, 1 with RF and 8 with AEDF). These
were seen among foetuses with IUGR and those whose
Figure 1. An example of reduced end-diastolic flow in Mulago
Figure 2. AEDF in the foetal umbilical artery. The mother was
26 years old and had pregnancy-induced hypertension. The
foetus was delivered prematurely by Caesarian section, admitted
to neonatal special care unit and died within 24 hours of
delivery. It was less than 2.5 kg. A similar flow pattern was
seen in 7 other foetuses, 4 of whom died (2 in utero and 2 after
delivery) and 3 survived.
Figure 3. RF at umbilical artery Doppler. The mother was 18
years old and had pregnancy-induced hypertension. The foetus
was born prematurely at 30 weeks and was a stillbirth after
induction of labour. The foetal weight at delivery was less than
1.5 kg.
Copyright © 2013 SciRes. OPEN A CCESS
P. Komuhangi et al. / Case Reports in Clinical Medicine 2 (2013) 554-561
Copyright © 2013 SciRes. OPEN A CCESS
mothers were hypertensive. This is in agreement with
studies which have shown that pregnancy induced hy-
pertension; along with intrauterine foetal growth restric-
tion (IUGR) have a significantly high association with
reversal of flow (RF) or absent end-diastolic flow
(AEDF) in the foetal umbilical artery [1,23,24,25].
None of the diabetic patients had foetuses with ab-
normal flow patterns. This is because they were very few
(only 4) those who could have had abnormal flow pat-
terns were not recruited.
AEDF/RF was associated with stillbirths or foetal
death within 24 hours of delivery. P =< 0.0001 OR 38.7
(6.61 - 226). This is reflected in Table 1. Only one of the
12 foetuses with reduced end-diastolic flow died within
24 hours of delivery. Diabetes mellitus, hypertension and
IUGR are all associated with placental insufficiency
which causes increased impedance of blood flow. This in
turn leads to AEDF or even RF and thus increases mor-
tality [32,33].
Four of the foetuses with AEDF survived but after be-
ing admitted to the special care unit (Ta bl e 1 ). The rea-
son why some of them survived and others died cannot
be explained by this study.
Premature delivery was common among foetuses with
abnormal flow patterns (Table 1). AEDF/RF was also
associated with low birth weight according to Table 1.
Hypertension and Diabetes in pregnancy are associated
with placental insufficiency which can lead to intrauter-
ine foetal growth restriction. This explains the majority
of foetuses being of a low birth weight [1]. Literature
also shows that abnormal flow patterns are associated
with premature deliveries because of early obstetric in-
tervention (Caesarian section and induction of labour)
The majority of foetuses with abnormal flow patterns
were born after an obstetric intervention (caesarian sec-
tion or induction of labour) as seen in Table 1.
Induction of labour is also one of the obstetric inter-
ventions used in Mulago Hospital and elsewhere besides
Caesarian section [48,49]. Most of the mothers who were
recruited had an intervention and the commonest inter-
vention was Caesarian section (52.60%). The main rea-
Table 1. AEDF/RF and foetal outcomes.
Variable Total AEDF/RF (%) OR (CI) P Value
Weight at delivery (kg)
>2.5 131 0 (0)
<2.5 59 9 (15.3)
Apgar score
0 - 2 12 4 (33.3)
5 - 7 27 4 (14.81) 0.35 (0.66 - 1.83) 0.192
8 - 10 153 1 (0.65) 0.01 (0.001 - 0.19) 0.000
Primary Outcomes
Term 126 1 (0.79)
Premature 65 8 (12.39) 17.54 (1.98 - 155.4) 0.0004
Secondary outcomes
Good 177 3 (1.69)
Stillbirth/ Death within 24 hours 15 6 (40) 38.7 (6.61 - 226) <0.0001
Gestational age at deliv er y (weeks)
37 - 42 122 0 (0)
28 - 36 70 9 (12.86)
Obstetric Intervention
Yes 154 8 (5.19)
No 36 1 (2.78) 0.52 (0.06 - 4.34) 0.54
Type of Intervention
Caesarian section 81 4 (4.94)
Induction 73 4 (5.48) 1.12 (0.27 - 4.65) 0.88
Admission to Neonatal special ca re unit
No 177 4 (2.3)
Yes 15 5 (50) 21.6 (5.2 - 42.1) 0.00
P. Komuhangi et al. / Case Reports in Clinical Medicine 2 (2013) 554-561
son for the caesarian section was to save the mother and
baby’s lives in high-risk pregnancy whether the umbilical
artery Doppler flow pattern is normal or abnormal. The
other intervention was induction of labour. Caesarian
section is done for those mothers whose foetuses are in a
poor condition because it is the quickest method of de-
livery. The Caesarian section rate in Mulago Hospital is
27% [9] compared to 15% recommended by WHO [50].
The reason for this is because Mulago is the national
referral hospital where most of the peripheral units refer
complicated cases many of which need to be managed by
Caesarian section. Induction of labour is done for those
mothers in a better condition and whose foetuses are not
in distress. Of the foetuses with abnormal flow patterns,
88.9% had an obstetric intervention and half of these
were Caesarian sections (Table 1). This study is in agree-
ment with other studies which have shown that there is
an increased Caesarian section rate in abnormal umbili-
cal artery Doppler findings [25,51].
Several studies have also shown that abnormal um-
bilical artery Doppler flow patterns are associated with
increased admission to the neonatal intensive care unit,
perinatal morbidity and mortality [25,48,51,52]. This is
similar to what was found out in this study: There was a
better outcome among foetuses with reduced end-dia-
stolic flow although many were born by Caesarian sec-
tion. This is because when there is reduced end-diastolic
flow, the foetus is not yet severely compromised and can
be saved by obstetric intervention.
The good outcome realized with the foetuses with high
resistance indices (Table 2) shows that in spite of this
finding, the foetus can survive if delivered early. It is
reported that if the resistance index is high and there is
diastolic flow, it may not be significant [17] so probably
some of the foetuses were not compromised.
According to the multivariate logistics model (Table
3), the foetuses with AEDF or RF were more at risk of
having an adverse outcome than the ones without. Those
born prematurely (28 - 36 weeks of gestation) were also
more likely to have an adverse foetal outcome than those
born at term. This is because of the increased mortality
that has been reported in premature babies [4]. Most of
the foetuses with adverse outcomes (14 out of 15) had a
birth weight of less than 2.5 kg (Table 2). It is well
known that a low birth weight is associated with a poor
foetal outcome [4,54]. Only one of those with an adverse
outcome had a weight of more than 2.5 kg. Fourteen of
the 15 foetuses with an adverse outcome had an Apgar
score of 0 to 7 while only one had an Apgar score of 8 to
10 (Ta b l e 3 ). Low 5 minute Apgar scores are predictive
of neonatal death in preterm infants [4].
Therefore apart from abnormal flow patterns, prema-
ture delivery, low birth weight and low Apgar score are
associated with adverse foetal outcome.
In this study, AEDF and RF were associated with a
low Biophysical profile score (Table 4).
Table 2. High resistance indices and foetal outcome.
Gestational age at deliv er y Total High RI OR (CI) P-value
37 - 42 94 14 (14.89)
28 - 36 56 20 (35.71) 3.17 (1.40 - 7.17) 0.00
Obstetric Intervention
Yes 123 30 (24.39)
No 26 4 (15.38) 0.56 (0.18 - 1.78) 0.32
Type of intervention
C/S 65 18 (27.69)
Induction 58 12 (20.69) 0.68 (0.29 - 1.58) 0.37
Primary Outcome
Term 96 16 (16.67)
Premature 53 18 (33.96) 2.57 (1.5 - 5.7) 0.02
Secondary Outcome
Good 141 32 (22.70)
Stillbirth 3 1 (33.33) 1.70 (0.15 - 19.59 0.85
Death within 24 hours 6 1 (16.67) 0.68 (0.76 - 6.09) 0.85
Apgar Score
0 - 2 7 1 (14.29)
5 - 7 21 4 (19.05) 1.41 (0.12 - 16) 0.77
8 - 10 122 29 (23.77) 1.87 (0.21 - 16.36) 0.48
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P. Komuhangi et al. / Case Reports in Clinical Medicine 2 (2013) 554-561 559
Table 3. Multivariate logistic model results.
Variable Total Adverse outcome (%) AOR (95%CI) P value
No 183 9 (4.9)
Yes 9 6 (66.7) 9.3 (2.2 - 92..47) 0.005
Gestational age at deliv er y (weeks)
28 - 36 70 11 (15.7)
37 - 42 122 4 (3.3) 0.014 (0.001 - 0.02) <0.001
Birth weight*
<2.5 kg 59 10 (17.0)
>2.5 kg 131 4 (3.1) 9.58e08
Apgar score*
8 - 10 153 1 (0.7)
0 - 7 39 14 (35.9) 4.06e+15
Table 4. AEDF/RF and the biophysical profile score.
Variable Total
(%) COR
(95% CI) P V alue
profile score
8 - 10 146 4 (2.74)
0 - 6 46 5 (10.87) 4.32 (1.1 - 17.2)0.023
Foetuses with abnormal flow patterns usually have a
poor outcome (Tab le 3). A low biophysical profile score
is also associated with a poor foetal outcome because
there is a high probability of foetal asphyxia with a score
of 4 - 6, and it is almost certain with a score of 0 or 2 [1].
Most of the foetuses with reduced end-diastolic flow
and those with high resistance indices had a Biophysical
profile score of 8 - 10 because they were not yet severely
compromised (Table 5). This is in agreement with a
study in Kenya which showed that Doppler ultrasound is
more sensitive than the biophysical profile score in de-
tecting foetal compromise [12] since the Doppler find-
ings were abnormal before the Biophysical profile.
According to the American College of Obstetricians
and Gynecologists (1999) there is no ‘best test’ to evalu-
ate foetal well-being. Therefore the Biophysical profile
should be used together with umbilical artery Doppler
Ultrasound to assess foetal well-being [55].
In conclusion, Doppler ultrasound of the foetal um-
bilical artery is important in predicting foetal outcome
and reducing on perinatal mortality. Therefore there is
need to avail ultrasound machines with Doppler applica-
tion to hospitals with maternity units and to train more
health personnel in using them.
The prevalence of abnormal umbilical artery flow
Table 5. High resistance indices and the biophysical profile
profile Tota l High RI (%) OR (CI) P Value
0 - 6 38 9 (23.7)
8 - 10 112 25 (22.32) 1.4 (0.44 - 4.61)0.39
patterns in high-risk pregnancy at Mulago Hospital is
10.95% (Reduced end-diastolic flow = 6.25%, AEDF
= 4.2% and RF = 0.5%) from this study.
AEDF and RF are related to poor foetal outcome.
Foetuses delivered before reduced end-diastolic flow
converting to AEDF or RF have better outcomes.
High resistance indices may not predict a poor foetal
There is a relationship between a low biophysical
profile score and AEDF/RF.
Umbilical artery Doppler ultrasound and Biophysical
profile should be done routinely for all high-risk
pregnancies above 28 weeks.
Radiologists and Obstetricians should be trained in
the use of Umbilical artery Doppler ultrasound be-
cause it aids in reducing perinatal mortality and pre-
dicting foetal outcome.
Ultrasound machines with Doppler application should
be available in all hospitals where high-risk pregnan-
cies are managed.
Studies including malaria and multiple pregnancies,
with longer follow-up periods should be done to find
out the trend in these conditions and any other long
term complications in foetuses with abnormal flow
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P. Komuhangi et al. / Case Reports in Clinical Medicine 2 (2013) 554-561
We wish to thank the following people for their support. The director
Mulago Hospital, Kampala for waiver of the ultrasound examinations.
The Radiologists and Postgraduates in Mulago Hospital and Makerere
University for their input in the research proposal and dissertation. Dr
Dan Kaye, Obstetrician and senior lecturer Makerere University for his
expert advice. Makerere University College of Health Sciences under
which this research was done.
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