Doppler Velocimetry of Maternal Renal
Circulation in Pregnancy-Induced
Hypertension
Hidehiko Miyake, MD, Akihito Nakai, MD, Tatsuo Koshino, MD, Tsutomu Araki, MD
Department of Obstetrics and Gynecology, Tama Nagayama Hospital, Nippon Medical School, 1-7-1 Nagayama,
Tama-shi, Tokyo 206-8512, Japan
Received 20 February 2001; accepted 22 May 2001
ABSTRACT: Purpose. The purpose of this study was
to evaluate whether the Doppler waveforms of the
maternal main renal, segmental, and interlobar ar-
teries are altered in women with pregnancy-induced
hypertension (PIH) compared with healthy pregnant
women.
Methods. Flow waveforms of the maternal main
renal, segmental, and interlobar arteries were ob-
tained from 42 healthy pregnant women between 24
and 41 weeks of gestation and 21 women with PIH
between 28 and 40 weeks of gestation using pulsed
Doppler sonography. We used spectral analysis to
measure the peak systolic and end-diastolic velocities
and the acceleration time. The presence or absence of
the normal early systolic compliance peak-reflective-
wave complex (ESP) was assessed in only the main
renal artery.
Results. The acceleration times of the segmental
and interlobar arteries were significantly prolonged in
the PIH group compared with those in the healthy
pregnant women. Of the 21 women with PIH, 3
showed loss of the ESP in the renal artery, but these
changes were not significant.
Conclusions. Decreased systolic acceleration and
the absence of ESP, the hemodynamic indicators for
significant proximal stenosis, suggest that severe
stenosis or continuous vasospasm in the proximal
arteries, such as the main renal or segmental artery,
may be implicated in the pathogenesis of PIH. ã 2001
John Wiley & Sons, Inc. J Clin Ultrasound 29:
449 455, 2001.
Keywords: acceleration time; Doppler ultrasonogra-
phy; pregnancy-induced hypertension; renal circula-
tion
Correspondence to : H. Miyake
ã 2001 John Wiley & Sons, Inc.
VOL. 29, NO. 8, OCTOBER 2001
H ypertension develops during pregnancy in
about 4 8% of nulliparous women. The hy-
pertensive disorders complicating pregnancy are
associated with substantial morbidity and mor-
tality rates. Despite improvements in obstetric
care, these disorders are the second leading cause
of maternal death.1 The perinatal mortality rate
is also increased as a consequence of placental
insufficiency, preterm delivery, and placental
separation.
The renal vascular pathologic condition of
pregnancy-induced hypertension (PIH) is associ-
ated with glomerular capillary endotheliosis.2
The constricted vascular bed in the kidney in PIH
diminishes the renal plasma flow and glomerular
filtration rate.2 Several Doppler sonographic
studies of renal circulation in healthy pregnant
women3 5 and women with PIH6 9 have been
performed, but the differences in Doppler indices
between the 2 groups have been inconsistent.
Hemodynamically significant arterial stenoses
cause changes in velocity waveforms that can be
detected with Doppler sonography in distal con-
tiguous arteries. Kotval10 reported such changes
in peripheral arteries and called them tardus-
parvus Doppler waveforms. In the poststenotic
region, these phenomena are observed on Dopp-
ler sonography as a prolonged acceleration time,
diminished systolic acceleration, and loss of the
normal early systolic compliance peak-reflective-
wave complex (ESP).10 The usefulness of these
indices in the evaluation for significant proximal
stenosis in the renal circulation and acute renal
allograft rejection has been suggested.11,12 Nakai
et al,13 who used Doppler sonography to evaluate
the maternal renal arterial circulation, demon-
449
 MIYAKE ET AL
strated a prolonged acceleration time and de-
creased systolic acceleration in the interlobar
arteries of women with PIH. The results sug-
gested that severe stenosis or permanent vaso-
spasm in proximal arteries might be implicated
in the pathogenesis of PIH. The measurements in
that study, however, were restricted to the in-
terlobar arteries.
In the present study, we evaluated whether the
Doppler waveforms of the maternal main renal,
segmental, and interlobar arteries are altered in
women with PIH.
PATIENTS AND METHODS
Between August 1999 and March 2000, we eval-
uated the Doppler velocity waveforms in the renal
arteries bilaterally in 47 pregnant women without
PIH between 24 and 41 weeks of gestation and 21
patients with PIH between 28 and 40 weeks of
gestation who were seen at our hospital. The preg-
nant women without PIH were randomly chosen
from outpatients who visited our hospital. We ex-
cluded from the study 5 pregnant women without
PIH because they had existing renal problems such
as significant hydronephrosis or horseshoe kid-
ney. However, we did not exclude women because
of technical reasons such as an inability to iden-
tify the renal vessels. Patients were included in
the study only if PIH had been diagnosed less
than 1 week previously and the patient had not
begun antihypertensive treatment at the time of
the Doppler sonographic study. None of the
women in the study had a history of renal disease
or essential hypertension. All participants pro-
vided written informed consent, and the study
was approved by the institutional review board.
PIH was defined as a blood pressure elevation
to higher than 140/90 mm Hg or a rise in either
the systolic (by >30 mm Hg) or diastolic (by >15
mm Hg) values over the baseline blood pressure
before 16 weeks of gestation in at least 2 mea-
surements obtained 6 hours apart.
Sonography was performed using an EUB-555
ultrasound scanner (Hitachi, Tokyo, Japan and a
3.5-MHz convex-array transducer). Each subject
was placed in the left lateral decubitus position,
and real-time imaging of the kidneys was per-
formed bilaterally to rule out gross abnormalities
in renal size, shape, and echogenicity. The kid-
neys were then scanned in the longitudinal plane
from a posterior approach. The course of the main
renal artery and its branches, the segmental and
interlobar arteries, was determined with color
Doppler flow mapping. The Doppler gate was then
450
placed over the investigated vessel. Angle-cor-
rected velocity waveforms were obtained in each
kidney; the insonation angles were less than 30°
during a period of suspended respiration. The
sample volume of the Doppler system was set at 3
mm, and a 100-Hz high-pass filter was used to
reduce the noise from the pulsating arterial wall.
Pulsed Doppler waveforms were displayed at
sweep speeds of 40 80 mm/second. All scans were
performed by the same operator.
Spectral analysis in the main renal artery, in
an isolated segmental artery, and in an isolated
interlobar artery included measurements of the
peak systolic and end-diastolic velocities and the
acceleration time. The presence or absence of the
normal ESP was assessed in only the main renal
artery because in the segmental and the interlo-
bar arteries, the ESP is commonly absent in
pregnant women.7,13 Values were calculated with
the built-in software of the scanner by placing
electronic calipers on the Doppler tracing dis-
played on the image monitor. At least 3 Doppler
waveforms were recorded in sequence, and the
best tracing obtained in each artery was selected
for analysis. The peak systolic and end-diastolic
velocities were measured at the apex of the
highest systolic peak and at the end of diastole,
respectively. The acceleration time was measured
from the beginning of the systolic upstroke to the
highest systolic peak in the waveform; any break
in the systolic upstroke before it reached its peak
was ignored. The systolic acceleration was cal-
culated by dividing the peak systolic velocity
during this same interval by the acceleration
time. Resistance index (RI) was calculated as
follows: (peak systolic flow velocity) end-diastolic
velocity)/peak systolic velocity.
All data except for the presence or absence of
ESP were expressed as mean ‹ standard devia-
tion. The unpaired t-test was used to compare the
values within each study group. The significance
of the presence or absence of ESP was analyzed
by the chi-squared test. Regression analysis was
used to evaluate relationships between Doppler
indices and diastolic arterial blood pressure. A p
value of less than 0.05 was considered to be sta-
tistically significant. The selection of an appro-
priate cut-off value for acceleration time in the
interlobar artery was determined using a re-
ceiver operating characteristic curve.
RESULTS
The characteristics of the healthy subjects and
the patients are given in Table 1. Gestational age
JOURNAL OF CLINICAL ULTRASOUND
 MATERNAL RENAL CIRCULATION IN PREGNANCY-INDUCED HYPERTENSION

FIGURE 1. Spectral analyses show waveforms obtained in the renal artery (A), a segmental artery (B), and an interlobar artery (C) in healthy
pregnant women compared with those in the renal artery (D), a segmental artery (E), and an interlobar artery (F) in women with pregnancy-
induced hypertension (PIH). In healthy pregnant women, the waveform of the renal artery demonstrates early systolic compliance peak-reflective-
wave complex (ESP), and the angle of the early systolic phase is acute in all 3 vessels. In women with PIH, however, ESP of the renal artery is
absent, the angle of the early systolic phase in the renal, segmental, and interlobar arteries is more rounded, and the acceleration time is
prolonged in waveforms from both the segmental and interlobar arteries.

at the time of examination, maternal age, and the
percentage of nulliparous women did not differ
significantly between the healthy women and the
patients with PIH. The systemic arterial blood
pressure differed significantly between the 2
groups (p < 0.001).
Typical Doppler waveform measurements in
healthy pregnant women and in women with PIH
VOL. 29, NO. 8, OCTOBER 2001
are shown in Figure 1. In both groups, there were
no significant differences in any of the Doppler
indices between the right and left kidneys.
The peak systolic and end-diastolic velocities,
RI, acceleration time, systolic acceleration, and
the presence or absence of ESP in the main renal
artery and the segmental and interlobar arteries
in both groups are shown in Table 2.
451
 MIYAKE ET AL

TABLE 1
Characteristics of Healthy Pregnant Subjects and

p Value

<0.001
<0.001
0.66
0.10
0.05
Patients with PIH

Analysis of Doppler Waveforms of the Renal Artery, the Segmental Arteries, and the Interlobar Arteries in Healthy Pregnant Subjects and Patients with PIH
Healthy Patients
Subjects with PIH p

0.05
0.02
0.06

0.86
Patients with

43.5
PIH (n = 21)
Interlobar Artery
Patient Characteristic (n = 42) (n = 21) Value

‹
‹
‹

‹
‹
0.24
0.09
0.62

1.89
Age, years* 30.8 ‹ 3.5 31.7 ‹ 3.4 0.57

135.4

NA
Nulliparity, no. 28 (67) 15 (71) 0.92
patients (%) 
Gestational age 33.5 ‹ 4.1 35.2 ‹ 3.3 0.09
at examination, weeks*

Healthy Subjects

0.23 ‹ 0.05
0.08 ‹ 0.03
0.65 ‹ 0.07

5.02 ‹ 2.55
Arterial blood pressure,

55.5 ‹ 24.2
mm Hg*

(n = 42)
Systole 113.2 ‹ 20.5 154.2 ‹ 19.1 <0.001
Diastole 69.9 ‹ 7.9 98.7 ‹ 10.8 <0.001

NA
Abbreviation: PIH, pregnancy-induced hypertension.
*
Values are given as mean ‹ standard deviation. Statistical analysis
by unpaired t-test.

p Value

<0.001
<0.001
Three of the 21 patients with PIH showed loss

0.87
0.27
0.24
of the normal ESP in the renal arterial Doppler
waveforms compared with none of the healthy

0.10
0.03
0.06

2.17
47.8
Patients with
pregnant women; but these changes did not reach

PIH (n = 21)
Segmental Artery
significance (p = 0.06). In the women with PIH,

‹
‹
‹
‹
‹
0.38
0.14
0.64

3.58
128.2
the peak systolic velocity of the renal artery was

NA
significantly decreased (p = 0.01) and the accel-
eration time was significantly prolonged (p =
0.02) compared with those in the healthy preg-

Healthy Subjects

0.38 ‹ 0.08
0.13 ‹ 0.03
0.65 ‹ 0.06

7.10 ‹ 2.51
59.5 ‹ 23.6
nant women. However, these changes might be

(n = 42)
TABLE 2

due to the absence of ESP in 3 patients with PIH.

In the segmental and interlobar arteries of the

NA
patients with PIH, the acceleration times were
significantly prolonged (p < 0.001) and the sys-
tolic acceleration values were significantly de-

Values are given as mean ‹ standard deviation. Statistical analysis by unpaired t-test.
creased (p < 0.001) compared with those in the
p Value

0.01
0.08
0.21
0.02
0.06

0.06
healthy pregnant women. The other indices (ie,
peak systolic velocity, end-diastolic velocity, and
RI) in the segmental and interlobar arteries did
Abbreviation: PIH, pregnancy-induced hypertension; NA, not applicable.
11.92 ‹ 7.30
0.57 ‹ 0.10
0.17 ‹ 0.04
0.67 ‹ 0.11
Patients with
PIH (n = 21)

77.2 ‹ 63.4

not differ significantly between the 2 groups

Renal Artery

(Table 2).
Figure 2 illustrates the correlation between the
18
3

acceleration time in the interlobar artery and the

diastolic arterial blood pressure. The acceleration
Healthy Subjects

time increased significantly with the increase in

15.46 ‹ 5.21
0.67 ‹ 0.14
0.20 ‹ 0.05
0.70 ‹ 0.06
46.0 ‹ 12.2

diastolic arterial blood pressure. The receiver

(n = 42)

operating characteristic curve indicated that in

42

the interlobar artery, an acceleration time of

0

Statistical analysis by chi-squared test.

100 msec was considered the best cut-off point for

distinguishing the 2 groups, showing a sensitivity
Systolic acceleration, m/second2*
*

End-diastolic velocity m/second*

Peak systolic velocity, m/second

of 83% and a specificity of 92%.

Acceleration time, msec*
Patient Characteristic

Present, no. patients

DISCUSSION
Absent, no. patients
Early systolic peak 
Resistance index*

In a normal pregnancy, large increases in renal

plasma flow and glomerular filtration rate result
from renal vasodilatation in the second trimester,
*
 

followed by slight decreases in the third trimes-

452 JOURNAL OF CLINICAL ULTRASOUND
 MATERNAL RENAL CIRCULATION IN PREGNANCY-INDUCED HYPERTENSION

FIGURE 2. Graph shows correlation between the acceleration time of the interlobar artery and the diastolic
arterial blood pressure. Open circles, healthy pregnant women; closed circles, women with pregnancy-in-
duced hypertension. These give the linear regression: AT = 2.2DBP)95; r2 = 0.52, where AT is acceleration
time (msec) and DBP is diastolic arterial blood pressure (mm Hg).

ter. In addition, plasma volume expansion occurs
with arteriolar vasodilatation followed by a de-
crease in arterial blood pressure.14 These renal
and cardiovascular adjustments are important
for the successful outcome of the pregnancy. In
contrast, PIH is associated with increased
peripheral vascular resistance in the maternal
circulation.15 The increased peripheral vascular
resistance in the kidneys decreases the renal
plasma flow and glomerular filtration rate.2
Therefore, considerable changes in the renal cir-
culation can be anticipated in patients with PIH
compared with women with a normal pregnancy.
Several investigators have attempted to eval-
uate renal circulation by performing Doppler so-
nography in healthy pregnant women3 5 and in
women with pre-eclampsia or PIH.6 9,16,17 Al-
though these studies evaluated the renal vessels
that can be detected with Doppler sonography,
such as the main renal artery, the segmental
arteries, and the interlobar arteries, the results
have been inconsistent. The diagnostic strategies
found to be promising in some studies were not
uniformly successful in other laboratories. How-
ever, the parameters analyzed in these studies3 9
were restricted to the most common parameters
of distal vascular resistance, such as systolic-di-
astolic ratio, RI, and pulsatility index. In our
study, the waveform indices for downstream
vascular resistance in patients with PIH did not
VOL. 29, NO. 8, OCTOBER 2001
differ from those in healthy pregnant women,
even in the interlobar arteries that might be more
likely than the proximal arteries to demonstrate
increased resistance to blood flow.
In the present study, we examined the accel-
eration time, the systolic acceleration, and the
ESP, which are the hemodynamic parameters for
substantial upstream stenosis. Severe stenosis of
an artery causes a pressure drop in the immedi-
ate poststenotic region, which results in a weak-
ened pulse in the downstream arterial network
that is clinically described as pulsus tardus (pulse
wave slow to rise) and pulsus parvus (small am-
plitude pulse).18 In the poststenotic region, these
phenomena are observed with Doppler sonogra-
phy as prolonged acceleration time, diminished
systolic acceleration, and loss of the normal
ESP.10 This principle is easily applied to the re-
nal arterial circulation. The evaluation of the
tardus-parvus waveform for the diagnosis of re-
nal arterial stenosis was initiated, to our knowl-
edge, with the work of Handa et al.11 These
investigators found substantial decreases in sys-
tolic acceleration distal to the renal arterial
stenosis. The results of our study, which demon-
strate prolonged acceleration time and dimin-
ished systolic acceleration in the segmental and
the interlobar arteries of women with PIH, are in
agreement with former observations of renal ar-
terial stenosis in nonpregnant women.11,12 The
453
 MIYAKE ET AL
prolonged acceleration time and decreased sys-
tolic acceleration in these arteries suggest the
possibility that vasospasm is a pathogenic event
for PIH and causes changes in the distal seg-
mental and interlobar arteries. In addition, be-
cause the acceleration time of the interlobar
artery showed a positive correlation with the di-
astolic arterial blood pressure, we speculated that
acceleration time could be effective as a routine
diagnostic tool for the severity of PIH.
In the present study, loss of the ESP in the
renal artery was noted in only 14% of women
with PIH. This finding suggests that in most
women with PIH, the vascular disturbance does
not occur upstream of the renal artery. Instead,
the blood flow disturbance may develop in the
main renal artery and/or the segmental artery in
women with PIH.
Previous studies showed that vasoconstriction
is involved in the pathophysiology of pre-
eclampsia.19 23 The present study is in accord
with these findings. Vasoconstriction causes en-
dothelial damage in the maternal circulation,
which leads to the involvement of various organ
systems (eg, kidneys, liver, brain, and coagula-
tion system).19 The results of studies20,23 in rats
and primates have shown that the inhibition of
nitric oxide synthesis during normal pregnancy
results in a clinical picture that is similar to that
of pre-eclampsia. Furthermore, a case report24
documented the benefits of a nitric oxide donor in
the treatment of HELLP (hemolysis, elevated
liver enzymes, low platelets) syndrome, suggest-
ing that nitric oxide contributes to the develop-
ment of hypertension in pregnancy as an
endothelium-derived relaxing factor.
More recently, Kanayama et al22 showed that
an animal model of HELLP syndrome can be
developed by stimulating the celiac ganglion in
rats. These researchers speculated that repeated
transient vasospasms of the renal artery induced
by catecholamines cause endothelial injury, re-
sulting in continuous vasospasm and hyperten-
sion. These pathologic and neurologic findings
suggest the background for the prolonged accel-
eration time and the diminished systolic acceler-
ation in the segmental and interlobar arteries in
our study. On the basis of these results, we
speculate that the blood flow disturbance in PIH
is due to severe stenosis or continuous vaso-
spasm, which may develop in the main renal ar-
tery, the segmental artery, or both but not in
more distal renal vessels.
We acknowledge that our series was probably
too limited to determine the pathogenesis of PIH
because of the relatively small number of patients
454
with PIH. This was because we selected only pa-
tients who were diagnosed with hypertension less
than 1 week previously and who had not begun
antihypertensive treatment at the time of the
Doppler study. However, we believe that our re-
sults provide new insight into the pathogenesis of
PIH and suggest the need for further study.
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