Fetal cerebral blood flow redistribution in late gestation: identification of compromise in small fetuses with normal umbilical artery Doppler

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Abstract
To evaluate the role of middle cerebral artery Doppler in small fetuses during the late third trimester. Prospective observational study of structurally normal fetuses with an estimated fetal weight < 5th percentile for gestation. Perinatal outcome was determined using a structured datasheet sent to each referring obstetrician. Structurally normal fetuses at 35 or more weeks of gestation referred during a 2-year period to the fetal growth clinic of a regional fetal medicine unit in North London. Fetuses with aneuploidy and/or major structural abnormalities were excluded. Umbilical artery and middle cerebral artery (MCA) Doppler waveforms were recorded and considered abnormal if above 95th or below 5th percentiles, respectively. Amniotic fluid was considered reduced if the maximum vertical cord-free pool was < 2 cm. The placenta was considered mature if the Grannum grade was II or III. The head circumference (HC)/abdominal circumference (AC) ratio was considered abnormal if > 95th percentile for gestation. Fetal growth, amniotic fluid, biophysical profile score and umbilical artery Doppler were used to advise the referring obstetrician about fetal well-being and he/she independently decided both the timing and mode of delivery. Forty-seven fetuses fulfilled the entry criteria. Thirty-four (72%) demonstrated normal umbilical artery Doppler waveforms. Sixteen (34%) demonstrated middle cerebral artery redistribution, of which nine (56%) had normal umbilical artery Doppler waveforms. MCA blood flow redistribution was associated with an increased incidence of cesarean delivery and need for neonatal admission. Of all gray-scale parameters, an elevated HC/AC ratio has the strongest association with MCA blood flow redistribution (15/16 vs. 1/31; P < 0.01). MCA Doppler may be a useful tool to assess the health of small fetuses in the late third trimester. Redistribution may occur in the presence of normal umbilical artery Doppler and should be suspected when the HC/AC ratio is elevated.

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