The Role of Uterine Artery Diastolic Notch and Uterine Artery

Pulsatility Index to Predict the Event of Early

Onset Preeclampsia

Muara Panusunan Lubis

, Sarma N. Lumbanraja

, Herman Hariman

, Adang Bachtiar

Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia;

Department of Clinical Pathology, Faculty of Medicine, Universitas Sumatera Utara, Medan, Indonesia;

Department of Health Policy and Administration, Faculty of Public Health, Universitas Indonesia, Jakarta, Indonesia

Keywords: Preeclampsia, uterine artery diastolic notch

Abstract: The uterine artery wave in the first trimester of pregnancy has a diastolic notch that disappears after 24

weeks of pregnancy. If the picture of this curve persists and the PI and RI values remain high, it means high

pressure on the uterine arteries which usually results in preeclampsia. This is a case-control study conducted

from March to November 2018 at several hospitals and private clinics in Medan, Indonesia. A total of 70

normal pregnant women within 22-24 weeks gestational age were enrolled and each 35 was grouped into

(A) patients with uterine artery diastolic notch and (B) patients without uterine artery diastolic notch. From

ultrasound examinations, 27 patients (38.6%) had unilateral uterine artery diastolic notch, and 8 subjects

(11.4%) had bilateral uterine artery diastolic notch. Five subjects (14.3%) had early onset preeclampsia,

with no significant difference between uterine artery diastolic notch with early-onset preeclampsia. No

significant differences were seen in average uterine artery pulsatility index between subjects with and

without early-onset preeclampsia, and between the presence of uterine artery diastolic notch and the

incidence of early-onset preeclampsia. However, a significant difference was seen between the pulsatile

value of the urine artery index and the incidence of early-onset preeclampsia (P=0.045).

1 INTRODUCTION

Indonesia is a country with the fourth highest

population in the world. The population in Indonesia

in 2017 according to the Statistical Yearbook of

Indonesia 2017 was estimated to be 258,704,900

people. Indonesia's population growth rate in 2000-

2010 was 1.49% per year (Central Statistics Agency,

2017), and the maternal mortality rate in Indonesia is

still high at 305 per 100,000 live births.

Hypertension is the second highest cause of maternal

mortality with a prevalence of 26%. The global

target of the 3rd SDGs (Sustainable Development

Goals) is to reduce the Maternal Mortality Rate

(MMR) to 70 per 100,000 live births by 2030.

(Ibrahimaj D, 2017; The Scientific World Journal,

2016)

Based on the Ministry of Health (2010),

preeclampsia occurs in around 10% of pregnancies

in the world. Developing countries contribute to the

incidence of preeclampsia greater than in developed

countries. Many theories suggest that the

pathogenesis of preeclampsia is related to the

placentation process, but to date, the pathogenesis of

preeclampsia is still unclear. Prevention and

predictive methods are still unknown. One theory of

the pathogenesis of preeclampsia is that it is thought

to be related to the failure of cytotrophoblast cells to

invade the maternal spiral arteries, thus causing

vascular injury and placental ischemia. (Siddiq A,

Mose JC, Irianti S, 2015) Preeclampsia is divided

into two, namely early onset and late onset. Early

onset preeclampsia which accounts for 5-20% of all

severe preeclampsia, but often causes severe clinical

cases. (Barton JR, Sibai BM, 2008; Akolekar et al,

2008, p 732-39)

In addition to examining the levels of pro-

angiogenic and anti-angiogenic factors, Doppler

velocimetry examination has been widely used to

predict the occurrence of preeclampsia. In Doppler

velocimetry, the blood flow can be seen clearly in

the uterine artery, arcuate, radial, and spiral around

the trophoblast tissue, so that measurements can be

Lubis, M., Lumbanraja, S., Hariman, H. and Bachtiar, A.

The Role of Uterine Arter y Diastolic Notch and Uterine Artery Pulsatility Index to Predict the Event of Early Onset Preeclampsia.

DOI: 10.5220/0009864002430246

In Proceedings of the 2nd International Conference on Tropical Medicine and Infectious Disease (ICTROMI 2019), pages 243-246

ISBN: 978-989-758-469-5

243

made on the various indices needed. Uterine artery

Doppler velocimetry examination to predict the

incidence of preeclampsia is better done in the

second trimester compared to the first trimester.

On the basis of the background above, the

authors are interested in examining the role of

uterine artery pulsatility index (PI) and uterine artery

diastolic notch in predicting the occurrence of

preeclampsia, so that preeclampsia can be predicted

as early as possible and strived to prevent the

occurrence of complications of preeclampsia.

(Nicolaides, 2002)

2 METHODS

This study used an analytical study design with

nested case-control. The study was conducted at

Bunda Thamrin Hospital, Tanjung Mulia Mitra

Medika Hospital, Sundari Hospital, and a private

clinic, from March to November 2018 with a sample

of 70 research subjects. The inclusion criteria are

pregnant women who were at gestational age 22-24

weeks and agreed to participate. An abnormal

Doppler velocimetry of the uterine arteries means

that 3 consecutive consistent waves are found in

uterine artery notch in either the unilateral or

bilateral uterine arteries and/or the pulsatility index

average >1.45. Data were analyzed using bivariate

analysis.

The study was approved by the Ethics

Committee of the Faculty of Medicine, Universitas

Sumatera Utara, Medan, Indonesia.

3 RESULTS

Of 70 pregnant women with gestational age 22-24

weeks, the majority was at 24 weeks (35 subjects,

50%) and were primigravid (31 subjects, 44.3%).

Baseline characteristics of patients are described in

table 1.

Table 1: Demographic characteristics of subjects

Characteristics n=70

Age of pregnancy, n (%)

22 weeks

23 weeks

24 weeks

22 (31.4)

13 (18.6)

35 (50)

BMI, mean (SD), kg/m

24.5 (4.0)

Parity, n (%)

Primigravid

Secundigravid

Multigravid

31 (44.3)

23 (32.9)

16 (22.9)

Using ultrasound it is known that as many as

50% of subjects had no uterine artery diastolic notch

(Table 2). A total of 27 subjects (38.6%) had

unilateral uterine artery diastolic notch and 8

subjects (11.4%) had bilateral uterine artery diastolic

notch.

Table 2: Result of uterine artery diastolic notch

examination of right and left uterine artery

Uterine Artery Diastolic Notch, n (%) n = 70

Without Uterine Artery Diastolic Notch 35 (50.0)

Unilateral Uterine Artery Diastolic Notch 27 (38.6)

Bilateral Uterine Artery Diastolic Notch 8 (11.4)

Observations on all subjects during the study

revealed that 65 subjects (92.9%) did not experience

preeclampsia, 2 subjects (2.9%) had preeclampsia

with proteinuria +3, and 3 people subject (4.3%)

with preeclampsia (proteinuria +4).

Of 35 subjects who had uterine artery diastolic

notch, there were 5 subjects (14.3%) who had early

onset preeclampsia. While a subject in subjects who

did not have a uterine artery diastolic notch, no

preeclampsia was found. The results of the analysis

using Fischer's exact test showed that no significant

association was found between uterine artery

diastolic notch and the incidence of early-onset

preeclampsia (P=0.054).

The average PI uterine artery in subjects

with early-onset preeclampsia was seen higher with

a mean of 1.4 (SD = 0.3) than in subjects who did

not experience preeclampsia with a mean of 1.1

(0.4).

Table 3: Relationship between age, parity, BMI, uterine

artery diastolic notch uterine artery PI and the incidence of

early-onset preeclampsia

Outcome

Preeclampsia

(n=5)

preeclampsia

(n=65)

Age, n (%)

>35 years

<35 years

0 (0)

5 (8.1)

8 (100)

57 (91.9)

1.000

Parity

Primigravid

Secundigravid

Multigravid

3 (9.6)

0 (0)

2 (12.5)

28 (90.4)

23 (100)

14 (87.5)

0.251

BMI, n (%)

Overweight-

obese

Underweight-

normoweight

1 (3.1)

4 (14.8)

31 (96.9)

23 (85.2)

0.169

Uterine artery

ICTROMI 2019 - The 2nd International Conference on Tropical Medicine and Infectious Disease

244

diastolic notch

Found

Not found

5 (14.3)

0 (0)

30 (85.7)

35 (100)

0.054

PI uterine

artery, mean

(SD)

1.4 (0.3)

1.1 (0.4)

0.045

Fischer's Exact;

T Independent; Mann Whitney

4 DISCUSSIONS

This study recruited as many as 70 (22-24 weeks)

pregnant women who came to the obstetrics and

gynecology outpatient clinics in Medan, Indonesia.

Patients aged<35 years dominated this study, with an

average of Body Mass Index of 24.5 kg/m

which is

classified into overweight. Patients with 24 weeks'

gestation were the most common ones, and also first

pregnancy patients (44.3%). Primigravidas one of the

risk factors for early-onset preeclampsia. While the

age of pregnant women<35 years and the nutritional

status of women in overweight or obese conditions

are risk factors for the occurrence of late-onset

preeclampsia.

We also found that the mean pulsatility

index of the right uterine artery is 1.09 and the left is

1.18, and the total pulsatility index of uterine arteries

is 1.135. Further, 50% of subjects had a normal

dichotomy, with 38.6% had unilateral uterine artery

diastolic notch and 11.4% had bilateral uterine artery

diastolic notch. However, this is not a predictor for

the incidence of early-onset preeclampsia. When we

use the pulsatility index mean value, we found that

mean value >1.4 is strongly associated with the

incidence of preeclampsia. Although another study

has reported a higher pulsatility index mean

value>1.55 to predict this occurrence. (Uyar et al,

2015)

Of 35 pregnant women who had a diastolic

notch, it was found that five experiencing early-onset

preeclampsia. Nevertheless, this association was not

significant and may be due to the small number of

samples. However, other studies have shown this

association where 23 patients with diastolic notch

had preeclampsia compared to 4 patient who also had

a diastolic notch but did not develop preeclampsia.

(Gomez-Arriaga P, et al, 2014)

5 CONCLUSIONS

a. We did not find a significant difference

between maternal age, body mass index and the

incidence of early-onset preeclampsia

b. There was no significant difference between

the presence or absence of uterine artery

diastolic notch and the incidence of early-onset

preeclampsia.

c. However, a significant association was seen

between the pulsatility value of the uterine

artery index and the incidence of early-onset

preeclampsia.

d. Examination on uterine artery PI can be

recommended as the early clinical sign to

predict early onset preeclampsia,

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