International Journal of Gynecology and Obstetrics (2007) 98, 115119

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m

w w w. e l s e v i e r. c o m / l o c a t e / i j g o

CLINICAL ARTICLE

Doppler assessment of uterine blood flow in recurrent pregnancy loss

A.M. Ferreira, C.R. Pires, A.F. Moron, E. Araujo Jnior , E. Traina, R. Mattar
Obstetrics Department of Sao Paulo Federal University (Unifesp/EPM), Sao Paulo, SP, Brazil Received 14 December 2006; received in revised form 29 April 2007; accepted 3 May 2007

KEYWORDS
Doppler ultrasonography; Recurrent miscarriage; Ultrasound

Abstract Objective: To compare uterine artery pulsatility index (PI) and flow velocity wave (FVW) patterns between women with no history of abortion and women with recurrent pregnancy loss of unexplained cause. Method: A cross-sectional study was conducted with 43 women with recurrent pregnancy loss and 43 women with no history of abortion and at least 1 child born at term (control group). Transvaginal ultrasonography with uterine artery Doppler evaluation was performed in the second phase of the menstrual cycle to calculate the PI and analyze the FVW pattern. Results: The women with recurrent pregnancy loss had a significantly higher uterine artery PI than those in the control group (2.71 0.54 and 2.30 0.44, respectively), as well as a higher incidence of FVWs of the A and B types. Conclusion: Compared with the control group, a higher PI and a higher incidence of FVW of the A and B types and thus a higher uterine artery impedancewere found among women with recurrent pregnancy loss. 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Abortion is considered habitual or recurrent when it occurs spontaneously and consecutively at least 3 times [1]. Recurrent pregnancy loss (RPL) affects 2% to 5% of women [2], and its etiology can be categorized into fetal and maternal. The most common fetal causes are genetic, with autosomal trisomy responsible for about 50% of abortions
Corresponding author. Rua Antonio Borba, 192 apt. 43, Alto de Pinheiros, So Paulo SP, Brazil. Tel.: +55 11 3022 8538/55 11 9368 5430; fax: +55 11 3672 8114. E-mail address: araujojred@terra.com.br (E. Araujo).

[3]. However, many cases of abortion remain with no defined etiology [46]. New methods have been developed to determine the cause of RPL in affected women [7,8]. Recent studies suggest that alterations in blood coagulation, such as antiphospholipid antibody syndrome and hereditary thrombogenic diseases, are related to recurrent abortion. The hemodynamic study of the uterus and ovaries during the menstrual cycle of fertile [9] and infertile women [10] has been facilitated with the technologic development that led, particularly, to the introduction of the Doppler scanner. However, vascular changes associated to RPL have not been sufficiently studied [11].

0020-7292/$ - see front matter 2007 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2007.05.006

116 Table 1
Endometrial thickness of patients, according to occurrence of RPL Endometrial thickness, mm Mean SD Median (range) P value a Control group 10.0 2.2 10.0 (5.015.0) 0.43 RPL group 9.6 2.7 9.0 (5.016.0)

A.M. Ferreira et al.

that might affect hemodynamic indexes; and a history oophorectomy and tubal ligation. All examinations were performed with a scanner (Powervision 6000 SSA-370-A; Toshiba, Tokyo, Japan) equipped with a 7.5-MHz endocavitary transducer with pulsed color Doppler. Examinations were performed in the second phase of the menstrual cycle, between days 18 and 23. The examinations began with pulsed color Doppler assessment of the right uterine artery (identified at the lateral border of uterine isthmus) and spectral wave analysis. The process was repeated for the left side. The PI reported was the arithmetic mean for the last 3 cardiac cycles, calculated with the same spectral morphology as the FVW. The Goswamy and Steptoe [13] classification was used to determine the wave types. According to this classification, the FVW of the circumflex artery can be of 3 types: Type A when the diastolic component is present but not continuous with the systole, and ends before the next cardiac cycle; type B when a diastole is present and continues with the systole, but ends before the next cardiac cycle; and type C when a diastole is present and continues with the systole and into the next cardiac cycle. The endometria were classified as proliferative when echogenicity was hypoechoic in relation to the myometrium; periovulatory when it was trilaminar; and secretory when it was hyperechoic. Qualitative variables were expressed as absolute (number) and relative (percentage) frequency. Quantitative variables are expressed as mean standard deviation and median (minimum, maximum). For qualitative variables, comparisons were performed using the 2 test or the Fisher exact test. For quantitative variables comparisons were performed using the t test for independent

Abbreviation: RPL, recurrent pregnancy loss. a By the t test (t = 0.79).

Studies suggest that uterine artery perfusion may regulate endometrial receptivity, and that poor uterine perfusion could be one of the causes of unexplained abortions [11,12] and, probably, of faulty implantation. In an effort to elucidate the vascular changes that occur in women with recurrent abortion, and identify women with poor uterine perfusion, we compared uterine artery pulsatility index (PI) and flow velocity wave (FVW) patterns between women with no history of abortion and women with a history of unexplained RPL.

2. Methods
From October 2004 to April 2006, an observational crosssectional study was conducted with 86 nonpregnant women at the Habitual Abortion section of the Obstetrics Department of Sao Paulo Federal University (Unifesp/EPM). All participants signed an informed consent form and the study was approved by the Ethics in Survey Committee of Unifesp. The participants were divided into 2 groups, those with a history of idiopathic RPL (the RPL group) and those who had no history of abortion and at least 1 child born at term (the control group). Inclusion criteria for the RPL group were the following: being between 18 and 40 years old; not being pregnant; having had regular menstrual cycles in the 3 months preceding enrolment; using neither hormonal contraceptives nor an intrauterine device; having a history of 3 or more unexplained abortions in the first trimester of pregnancy; and having no living child. Autoimmune and endocrine disorders were ruled out in the women with idiopathic RPL, and a thorough uterine evaluation revealed nothing abnormal. In this group titers were less than 20 GPL for IgG anticardiolipin antibody and less than 20 MPL for IgM anticardiolipin antibody; values for activated partial thromboplastin time were normal; and no antinuclear or lupus anticoagulant antibodies were detected. The endocrine evaluation consisted in measuring thyroid-stimulating hormone, free thyroxin (T4), and progesterone levels on days 19 and 21 of the menstrual cycle, and the results were normal. Results to the glucose tolerance test were also normal. Hysterosalpingography revealed no abnormalities of the uterine cavity and transvaginal ultrasonography revealed no abnormalities to the secretory endometrium. Inclusion criteria for the control group were the following: being between 18 and 40 years old; not being pregnant; having had regular menstrual cycles in the 3 months preceding enrolment; using neither hormonal contraceptives nor an intrauterine device; having a normal obstetric history with no abortions; and at least 1 child born at term. Exclusion criteria for both groups were having uterine alterations on transvaginal ultrasonography; systemic diseases

Table 2

Uterine artery pulsatility indexes in the control and RPL groups Variables PI, right and left sides combined Mean SD Median (min, max) t test (t = 3.865) PI, right side Mean SD median (min, max) t test (t = 3.006) PI, left side Mean SD Median (min, max) t test (t = 3.68) Conditioned PI a Mean SD Median (min, max) t test (t = 3.46) Control group, RPL group, n = 43 n = 43

2.30 0.44 2.37 (1.08, 3.10) P b 0.001 2.33 0.49 2.24 (1.10, 3.47) P = 0.004 2.26 0.52 2.35 (1.06, 3.22) P b 0.001 2.10 0.43 2.21 (1.10, 3.02) P = 0.001

2.71 0.54 2.78 (1.69, 3.47)

2.72 0.69 2.81 (1.19, 3.88)

2.70 0.57 2.77 (1.54, 3.66)

2.49 0.59 2.60 (1.19, 3.82)

Abbreviation: PI, pulsatility index; RPL, recurrent pregnancy loss. a PI ipsilateral to the corpus luteum.

Doppler assessment of uterine blood flow in recurrent pregnancy loss

samples if the samples presented a normal distribution, or by the MannWhitney test otherwise. The t test was used for paired samples to compare the PIs of the right and left uterine arteries within each group. Agreement between the wave types found on the right and left uterine arteries was assessed by the coefficient within each study group. The significance level adopted was 0.05 and descriptive levels (P values) less than 0.05 were considered significant.

117

3. Results
To form the sample, 108 nonpregnant women were evaluated. Of these, 22 (20.4%) were excluded, 9 (8.3%) from the RPL group and 7 (6.5%) from the control group, because they had uterine myomas (n = 14) and pelvic tumorations (n = 2). Six women (5.5%), 4 from the RPL group and 2 from the control group, were also excluded because it could not be ascertained that they had a secretory endometrium at the time of examination. The mean SD age was 29.8 6.5 years in the RPL group and 32.7 4.4 years in the control group. Most women had a history of 3 (76.7%) or 4 (21.0%) abortions in the RPL group whereas most were primiparas (44.1%) or secundiparas (48.8%) in the control group. Endometrial thickness was 9.6 mm 2.7 mm (median, 9 mm) in the RPL group and 10.0 mm 2.2 (median, 10 mm) in

Figure 1 ROC curve of the mean uterine artery PIs of women with RPL. The solid line represents IP medians. PI indicates pulsatility index; ROC, receiver operating characteristic; RPL, recurrent pregnancy loss.

Table 3
Variable

Distribution of the FVW types in the uterine arteries of women with RPL and controls Control RPL group, group, n (%) n (%)

FVW types right and left sides combined A/A A/C B/B B/C C/A C/C FVW type, right side A B C Pearson 2 test (2 = 11.27) Left-side FVW type A B C Pearson 2 test (2 = 13.72) FVW type ipsilateral to the corpus luteum A B C Pearson 2 test (2 = 10.74)

1 (2.3) 1 (2.3) 1 (2.3 0 0 40 (93.0) 2 (4.7) 1 (2.3) 40 (93.0) P = 0.004 1 (2.3) 1 (2.3) 41 (95.3) P = 0.001

6 1 7 1 2 26

(14.0) (2.3) (16.3) (2.3) (4.7) (60.5)

7 (16.3) 8 (18.6) 28 (65.1)

8 (18.6) 7 (16.3) 28 (65.1)

1 (2.3) 1 (2.3) 41 (95.4) P = 0.005

6 (14.0) 7 (16.3) 30 (69.7)

the control group, but the difference was not significant by the t test (P = 0.431) (Table 1). The results of the Doppler studies of the uterine arteries for both groups are shown in Table 2. The differences between groups were all statistically significant: PI of right and left uterine arteries (P b 0.001); PI of the right uterine artery only (P = 0.004); PI of the left uterine artery only (P b 0.001); and PI of the uterine artery ipsilateral to the ovary where the corpus luteum was located (P = 0.001). The paired t test was applied to each of the proposed analyses to compare the uterine artery PIs on the right and left sides within the groups (Table 2). There were no statistically significant differences between the PIs of the right and left side (P = 0.37) and (P = 0.86), respectively. As for the distribution of the FVW types according to the criteria proposed by Goswamy and Steptoe [13], statistically significant differences were found between the groups (Table 3). Flow velocity wave analyses were performed for the right uterine artery only (P = 0.01), the left uterine artery only (P = 0.004), and the uterine artery ipsilateral to the corpus luteum (conditioned PI) (P = 0.01). Compared with the RPL group, the combination type of C/ C waves was more frequently found in the control than in the RPL group (93% vs. 60.5%) (Table 3). A high degree of agreement between the FVW types of the right and left uterine arteries was found in both the RPL ( = 0.810) and the control group ( = 0.791). Within each group, the uterine arteries showed a similar spectral morphology. The application of the receiver operating characteristic (ROC) curve for the means of uterine arteries PIs showed that a cut-off value greater than 3 was the best discriminator for women at risk for RPL. This cut-off value had the best sensitivity (0.349) and specificity (0.930) (Fig. 1).

4. Discussion
The main objective of this study with nonpregnant women was to determine whether women with a history of unexplained RPL had a higher uterine blood flow impedance

Abbreviation: FVW, flow velocity wave; RPL, recurrent pregnancy loss. According to the classification proposed by Goswamy and Steptoe [13].

118 than women who had at least 1 live child and no history of spontaneous abortions. Some studies mention that a poor uterine perfusion might be one of the causes of unexplained infertility [10,12]. However, few studies correlate RPL and Doppler flowmetry of the arteries responsible for uterine perfusion. The women in the RPL group had a mean age of 30 years, which was similar to the mean age in a study by Habara et al. [11], and older than the age considered ideal for pregnancy, which is between 18 and 25 years [14]. Fertility progressively decreases with age, and reports impute this decrease to lesser embryo quality and fewer favorable implantation areas [15]. Modifications in cardiac capacity and vessels walls may be a result of aging. Some studies, e.g. one by Ziegler et al. [16], have suggested that low levels of progesterone might cause the uterine vascular impedance to increase. Therefore, using the secretory endometrium as an inclusion criterion in the present study, and establishing the location of the corpus luteum, were intended to determine (however indirectly) whether hormonal action was adequate in our group of women with RPL, and to ensure that the examination occurred during the luteal phase. There was no statistically significant difference in endometrial thickness between the groups. In a study by Jirous et al. [17], endometrial thickness was 8.79 1.87 mm in patients with RPL, a finding similar to ours, which was obtained when the Doppler evaluation was performed. Habara et al. [11] observed a thicker endometria in controls (11.5 mm) than in women with RPL (10.4 mm). Because different thicknesses might indicate different hormonal levels and affect the Doppler evaluation, it is important to establish endometrial similarity for the study of uterine artery impedance. In this study, the women with a history of RPL had a higher blood flow impedance than the controls. This finding is in agreement with those of Habara et al. [11], who reported mean PI values of 2.44 0.41 in their RPL group and 2.19 0.40 in their control group (P b 0.01). Likewise, Jirous et al. [17] found increased ovarian and uterine flow impedance in women with RPL than in controls. Similar results were previously observed by Goswamy et al. [12] and by Steer et al. [10], who described differences in uterine blood flow between fertile and infertile women and suggested that a bad uterine perfusion might be one of the causes of infertility. On the other hand, no statistically significant difference between the PIs of the right and left uterine arteries could be found within the groups, just as was reported by Steer et al. [10]. And because no difference between the right and left sides can be detected, it seems possible to affirm that the best way to interpret Doppler data for uterine arteries would be through the mean PI of both sides combined. No influence of the corpus luteum could be observed in the ipsilateral uterine vascularization in this study, and in a study by Scholtes et al. [18] they report lower uterine artery PIs on the side where the corpus luteum was developing. Some studies verified that lower uterine artery PI values are found in the midluteal phase, suggesting an increased perfusion of the organ during the period of ovular implantation [9,12,19]. In this study, increased values were found in the RPL group during that period. This finding leads us to assume that the increased vascular impedance causes a poor

A.M. Ferreira et al. uterine perfusion, resulting in poor decidual formation and poor initial development of the gestation. Pulsatility indexes higher than 3.0 were found mostly in the RPL group, although values less than 3 were frequently found in both groups. Lower mean PI values were also found more frequently in the controls. Those findings suggest that, in women in the luteal phase, the risk of spontaneous abortion is higher for those with PIs higher than 3.0 and lower for those with PIs less than 1.75. The differences between the groups were not significant when the PI was between 1.75 and 3.0, and therefore no prediction can be made when PI values are in this interval. Still, a cut-off value greater than 3.0, established in this study by the ROC curve of the mean PIs of the uterine arteries, would need to be validated in other populations. The study also showed that the women in the RPL group had a lower frequency of type C/C FVW than the controls (60.4% vs. 93%) (FVWs of the 0 type were not found in either group). These results are similar those reported in the medical literature that correlate type C waves with better uterine perfusion and better rates of embryo implantation in assisted fertilization [20]. Kurjak et al. [21] reported that type C waves prevailed in their group of fertile women and that no type 0 wave was found in this group, but that waves of the 0, A and B types were predominant (80%) in their group of infertile women. The results of the present study suggest that, for women evaluated by transvaginal ultrasonography with Doppler flowmetry in the second phase of the menstrual cycle, those with PIs of 1.75 or less and type C waves may have a low risk of unexplained RPL; but that those with PIs greater than 3.0 and type 0, A or B waves may have an increased risk of abortion due to poor uterine perfusion. Based on these findings, it is possible to propose the use of transvaginal ultrasonography with Doppler flowmetry in the second phase of the menstrual cycle to assess uterine artery flow and local perfusion in women at risk for spontaneous abortion and obtain a prognostic cut-off value. In-vitro fertilization programs could also use this method to identify women with a higher probability for endometrial receptivity and adequate embryo development before the embryo is transferred. However, it must be noted that the number of cases analyzed by this study was small, and that similar previous studies are few. New studies are necessary, ideally multicenter studies, to better elucidate the association between spontaneous abortion and inadequate uterine perfusion, identified through a Doppler evaluation of the uterine arteries.

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