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Ginekologia i Poloznictwo
ISSN 1896-3315 e-ISSN 1898-0759

Research - (2022) Volume 17, Issue 4

Dopplar ultrasound study of subendometrial blood flow in women with recurrent miscarriage in the first trimester

Ali A. Bendary* and Ibrahim I Souidan
*Correspondence: Ali A. Bendary, Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Egypt, Email:

Received: 15-Nov-2022, Manuscript No. gpmp-22-79790; Editor assigned: 16-Nov-2022, Pre QC No. P-79790; Reviewed: 30-Nov-2022, QC No. Q-79790; Revised: 06-Dec-2022, Manuscript No. R-79790; Published: 29-Dec-2022

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Recurrent miscarriage (RM), which occurs 0.5–1% of couples, is defined as three or more consecutive miscarriages, before the 20th week of pregnancy. Recurrent miscarriages are associated with changes in blood coagulation, including antiphospholipid antibody syndrome and hereditary thrombogenic diseases. The Doppler of the blood flow of the subendometrial arteries allows for a non-invasive method to evaluate uterine perfusion.

Aim of the work: to characterize the sub-endometrial blood flow in recurrent miss-carriage women and thereby to suggest better therapeutic strategy.

Methods: 120 women (60 in each group) who met the inclusion and exclusion criteria were included in this study, The following was administered to all patients: History and clinical evaluation vibrant pulses Pulsed color Doppler of uterine artery.

Results: Resistance Index and Pulsatility Index show a large and statistically significant difference between the groups under study. The case group outperformed the control group.

Conclusion: Women with RPL appear to have much decreased subendometrial blood flow. Therefore, non-invasive techniques such as measuring endometrial thickness and subendometrial blood flow are advised in cases with RPL.


Doppler; Subendometrial blood flow; Recurrent miscarriage


Three or more recurrent miscarriages before the 20th week of pregnancy are considered recurrent miscarriage (RM), which affects 0.5–1% of couples [1]. Genetic, anatomical, endocrinological, immunological, microbiological, placental defects, hormonal issues, infections, smoking, alcohol use, exposure to environmental risk factors, psychological trauma, stressful life events, and certain coagulation diseases are all categorized as RM causes. However, there are still a large number of miscarriages whose causes are unknown [2].

Transvaginal shade Uterine perfusion can be assessed non-invasively methods used in conjunction with obstetric ultrasound to learn more about the existence, direction, and velocity of blood flow [3,4].

Uterine receptivity is crucial to producing a healthy pregnancy and is probably regulated by a variety of variables, including uterine perfusion [5].

Numerous studies have been conducted that demonstrate how low pulsatility index and high blood flow resistance are both linked to lowered conceiving rates in women (PI) values falling pregnant is higher. This is not the general consensus, however, as numerous researchers have been unable to show a connection between aberrant Obstacles to conception and uterine perfusion The development of three-dimensional power Doppler sonography (3D-PDS) has made it possible to quantitatively assess the vessel density and perfusion in the subendometrial area, which may offer insight into the association between the general blood supply in the subendometrial area and pregnancy rate and complications. The 3D ultrasound with power Doppler is a unique device for assessing the blood flow to the entire endometrium and the subendometrial region [6,7].

Aim of the Work

To characterize the sub-endometrial blood flow in recurrent miss-carriage women and thereby to suggest better therapeutic strategy.

Patient and Methods

The study was a Case control study which included 120 non pregnant women from year Marsh 2021 to Marsh 2022.


1) Participants in the study group (N=60) had experienced three or more idiopathic spontaneous recurrent pregnancy losses (the RPL group).

2) Control group (N=60): people who had at least one healthy child born at term and no history of abortion (the control group).

Selecting a patient

All patients met the following inclusion and exclusion standards:

1. Be in the 20–40-year-old range.

2. Not being expecting.

3. Experiencing normal menstrual cycles for the three months before to enrollment.

4. Not using either hormonal or intrauterine contraception.

5. Having a normal obstetric history that includes no miscarriages and at least one term birth.

One history of consanguinity is an exclusion factor.

1. A history of chromosomal abnormalities in the family, such as Turner's disease, trisomy 21, and trisomy 13.

2. The patient's age, either under 20 or above 40.

3. Immune system conditions.

4. Endocrine problems.

5. Transvaginal ultrasonography reveals uterine abnormalities.

6. Previous tubal ligations or oophorectomy.

7. Age below 20 or more 40 years old.

Study procedure

1) Detailed history taken

2) Complete clinical examination

3) Laboratory investigations

• Routine investigations were done including: kidney functions, liver functions, fasting and postprandial blood sugar, CBC and urine analysis were done for both the (idiopathic recurrent abortion) group and the control group.

4) Sonography and Doppler study

• A 7.5 MHZ endocavitary transducer with pulsed color Doppler and 3D capabilities was used for the sonography and pulsed Doppler system for blood flow analysis. The spatial peak temporal range average intensity was approximately 80mW/cm2. Wall filters (50Hz) were used to eliminate low-frequency signals. Subendometrial vessels were usually visualized at the periphery of the endometrium. Sometimes they penetrated the hyperechogenic endometrial edge or even reached the endometrial cavity. The blood flow velocity waveforms from the subendometrial vessels were obtained by placing the Doppler gate over the color area and activating the pulsed Doppler function. A recording was considered satisfactory when at least 5 consecutive waveforms were obtained, each demonstrating the maximum Doppler shift. The resistance index (RI = peak systolic velocities – peak diastolic velocities/peak systolic velocities) was calculated on 3 consecutives uniform heartbeats.

Statistical analysis

Data collection and statistical analysis: Version 25 of the Statistical Package of Social Services (SPSS) was used to enter and analysis the gathered data


Tab. 1. shows no statistically significant difference between the studied groups in age distribution. Tab. 2. shows high statistically significant difference between the studied groups in Resistance Index and Pulsatility Index. Case group had significantly higher RI than control group. Tab. 3. Shows that RI and PI were significant predictors of recurrent Pregnancy loss. Regression model was a good-fit-model as Hosmer and Lemeshow test was non-significant.

Age (years) Case group (n=60) Control group (n=60) t-test P
Mean ± SD 29.2 ± 4.1 27.4 ± 4.1 1.5 0.1
Median 30.0 26.0
Range 21.0 – 35.0 22.0 – 36.0

Tab. 1. Distribution of age in the studied groups.

RI Case group (n=60) Control group (n=60) t-test P
Mean ± SD 0.79 ± 0.09 0.63 ± 0.11 6.0 <0.001
Median 0.80 0.60
Range 0.59 – 0.89 0.50 – 0.89
PI Case group (n=60) Control group (n=60) MW-test P
Mean ± SD 2.5 ± 0.17 2.1 ± 0.25 1.9 <0.001
Median 2.6 2.2
Range 2.1 – 2.8 1.8 – 2.5

Tab. 2. Resistance Index (RI) and Pulsatility Index (PI) distribution in sub-endometrial blood flow in the groups of the study.

Variables B S.E. Wald Sig. Exp.(B) 95%CI
Resistance Index (RI) 10.0 3.5 8.3 0.004 (S) 21.9 2.4 – 200.1
Pulsatility Index (PI) 0.57 0.19 9.1 0.003 (S) 0.56 0.39 – 0.82

Tab. 3. Binary logistic regression analysis for prediction of recurrent Pregnancy loss using sub-endometrial blood flow Doppler.


This study's primary goal was to compare the uterine artery blood flow of normal fertile women versus women who experienced unexplained recurrent miscarriage: 120 patients were divided into two groups:

Study Group RPL (patients): 60 cases with 3 recurrent spontaneous abortion.

Control group: 60 cases of females with normal obstetric history and at least one term.

In terms of age and BMI There was no discernible age difference between the studied groups. The mean and standard deviation (SD) ages of the patients and controls were (29.2 ± 4.1) and (27.4 ± 4.1), respectively. Additionally, there was no discernible variation in BMI between groups. Patients and controls had mean SD BMIs of (25.5 ± 3.7) and (24.4 ± 3.3), respectively. The patient and control groups so had similar BMIs and ages.

Study by Garhy, et al. found that the age of the patients in the recurrent miscarriage group and the control group was not significant (28.6 ± 4.6 years and 26.2 ± 4.7 years, respectively) (p = 0.06), which is in contrast to earlier studies by Garhy, et al. Their findings were consistent with our findings [8].

This agree with other study showed that women with unexplained RPL have been reported to have a significant rate of reduced ovarian reserve [9,10].

Endometrial thickness and volume, endometrial pattern, and blood flow in the uterine and sub endometrial arteries are among the possible uterine indicators for implantation that are quantifiable by U/S [11].

The subendometrial resistance index in the current study was 0.79 ± 0.09 vs 0.63 ± 0.11 in the case and control groups, respectively. The RI in the case group was substantially greater than in the control group. This study demonstrates the diagnostic performance of the Resistance Index (RI) in the prediction of RPL at a cutoff point of 0.71, sensitivity and specificity of 84.6% and 84.6%, respectively, and accuracy of 84.6% with respect to both positive and negative predictive values. Statistically significant was the area under the curve.

If endometrial blood flow and thickness could forecast IVF success, Yuval et al. investigated this possibility. The endometrial pulsatility and resistance indices, the systolic/diastolic ratio, and the endometrial thickness were all evaluated in the authors' study of 156 cycles in patients with RPL. RPL did not appear to be correlated with endometrial thickness or endometrial blood flow [12]. Also, Salle et al. sonographically examining 96 women with RPL did not reveal any significant differences in endometrial blood flow between the study groups (P = 0.27) [13].

According to Schild et al. analysis of 135 RPL patients, they discovered that the case and control groups' respective mean spiral artery PI values were 1.12 ± 0.28 and 1.21 ± 0.27, with a P value of 0.322. (Non-significant). They came to the conclusion that sonography of the spiral artery does not accurately predict RPL [14].

According to numerous studies, low Pulsatility Index (PI) values are connected with the highest chances of conception while high blood flow resistance is linked to reduced conception [15].

The 3D-power Doppler technology may allow medical professionals to conduct a more in-depth examination of the area of concern [16].

Our findings were supported by a study Rifat, et al. that discovered a significant difference. These results suggest that an early pregnancy failure may be brought on by a subclinical vasculopathy that is impairing uterine blood flow [17].

Contrarily, other studies asserted that Doppler ultrasound is inadequate for predicting the course of early pregnancy and that the vascular impairment in the uteroplacental circulation in abnormal pregnancies is too subtle to be detected by the Doppler ultrasound. Their contrasting results may be explained by the variety of miscarriage causes and the utilization of different study groups [18,19].


Women with RPL appear to have much decreased subendometrial blood flow. This would imply noticeably worse angiogenesis during the anticipated peri-implantation interval, which might be an etiological factor in RPL-affected women. Therefore, non-invasive treatments such as subendometrial blood flow are advised in cases of RPL.

Authors Contribution

(A) Study Design · (B) Data Collection . (C) Statistical Analysis · (D) Data Interpretation · (E) Manuscript Preparation · (F) Literature Search · (G) No Fund Collection


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Author Info

Ali A. Bendary* and Ibrahim I Souidan
Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Egypt

Copyright:This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.