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Umbilical Doppler Waveforms and Placental Villous Angiogenesis in Pregnancies Complicated by Fetal Growth Restriction

From the Departments of Obstetrics and Gynaecology and Neuro-science, University of Torino, Torino, Italy; Department of Anatomy, Technical University of Aachen, Aachen, Germany; and Program in Development and Fetal Health, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Canada.

Address reprint requests to: Tullia Todros, MD, Department of Obstetrics and Gynaecology, Via Ventimiglia 3, 10126 Torino, Italy, E-mail: todros{at}iol.it

Objective: To test the hypothesis that the characteristics of umbilical artery Doppler flow velocity waveforms in growth-restricted fetuses indicate angiogenesis within placental stem and gas-exchanging villi.

Methods: We examined 18 placentas from singleton fetuses that were normal structurally and chromosomally but were growth-restricted, preterm, and complicated by preeclampsia. Ten cases with positive end-diastolic flow and eight with absent or reverse end-diastolic flow were compared with six gestational age-matched controls. Sections of villous placenta were examined to determine structural composition (percentage of fibrinoid, intervillous space, and villous tissue), relative proportion of villous types (stem, immature intermediate, and gas-exchanging villi), and the frequency distribution of stem arterial vessel calibers and their branching pattern.

Results: Placentas with positive end-diastolic flow had a significantly (P < .05) higher percentage of gas-exchanging villi (median 69.6%, range 62.5–80.8%) than those with absent or reverse end-diastolic flow (58.3%, 29.9–71.9%) or controls (60.8%, 43.1–65.6%). The gas-exchanging villi from placentas with absent or reverse end-diastolic flow were slender, elongated, poorly branched, and poorly capillarized. There was a progressive trend toward reduced branching of the stem arteries from the controls (median 22%, range 2–38%), through the positive end-diastolic group (17%, 11–20%), to the absent or reverse end-diastolic group (13%, 4–23%).

Conclusion: Compared with absent or reverse end-diastolic flow, the placentas from growth-restricted fetuses with positive end-diastolic flow showed a normal pattern of stem artery development, accompanied by increased capillary angiogenesis and terminal villous development. These features suggest an adaptive pathway for the placenta in the face of uteroplacental ischemia.

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