Uterine artery Doppler in predicting pregnancy outcome in women with connective tissue disorders

SIR, We read with great interest the article by Le Thi Huong et al. [1] on the second trimester Doppler ultrasound as best predictor of late pregnancy outcome in patients with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). The authors prospectively examined 100 high-risk pregnancies and concluded that Doppler examination and history of thrombophlebitis were independent predictors of fetal and neonatal death in SLE and APS pregnancies progressing beyond 22 weeks. Infact, six out of eight fetal/neonatal deaths and other major and minor obstetric complications occurred in patients with abnormal second trimester Doppler ultrasound. In order to investigate the role of uterine Doppler ultrasound abnormalities as a risk factor for adverse pregnancy outcome, we have prospectively followed 40 pregnancies in 40 patients with SLE and other connective tissue diseases including vasculitis: six patients were affected by APS, nine patients by SLE, 12 patients by undifferentiated connective tissue disorder (UCTD), three patients by Behc¸ et’s disease (BD), four patients by scleroderma (Scl) and five patients by Sjo¨ gren’s syndrome (SS). The second trimester fetal Doppler ultrasound examination was abnormal in 14 pregnancies: in 45% of the SLE patients (four out of nine), in 67% of the APS patients (four out of six), in 75% of patients with BD (three out of four) and 100% of the Scl patients. Out of 14 pregnacies, 11 were complicated by premature deliveries associated, with pre-eclampsia in four cases and with premature membrane ruptures (PROM) in the other four. There was one delivery of a growth-restricted liveborn (intrauterine growth retardation, IUGR). Only two of these 14 pregnancies progressed until the end of the third trimester and delivered spontaneously. The mean gestational age at delivery was 35 weeks, the mean birth weight was 2142 g and the mean APGAR scores at 5 and 10 min were, respectively, 8 and 8. All the 26 patients with a normal arterial uterine Doppler ultrasound examination at the second trimester delivered uneventfully. There was only one premature delivery due to PROM in an SLE patient. The mean gestational age at delivery was 39 weeks, the mean birth weight was 3200 g and the mean APGAR scores at 5 and 10 min were, respectively, 9 and 10. Although literature data addressing the role of uterine artery Doppler screening as predictor of poor outcome are contradictory [2-7], in agreement with Le Thi Huong et al.’s [1] result, our study confirms how pregnancy outcome of patients with abnormal uterine waves is worse when compared with a woman with normal Doppler. In fact, abnormal Doppler velocimetry was related to an increased prevalence of PROM, IUGR, maternal and perinatal complications (low birth weight and low APGAR score). Not surprisingly, due to the important role of vascular damage, apart from APS and SLE patients, Scl and BD patients were at very high risk as well. In contrast to Le Thi Huong et al. [1] data and probably due to the lower number of patients examined, Doppler abnormalities were not associated with an increased rate of neonatal or fetal death. In conclusion, it is our opinion that Doppler velocimetry should be considered as a reliable and useful tool to identify SLE and other CTD patients at higher risk in order to start a proper therapy.