ISUOG Practice Guidelines (updated): use of Doppler velocimetry in obstetrics

Fetal Aortic Isthmus Doppler Evaluation in Pre-Eclampsia Patients

PURPOSE

This study aimed to evaluate the role of fetal aortic isthmus (AoI) Doppler parameters in predicting adverse perinatal outcomes in pre-eclampsia patients.

METHODS

This prospective study included 60 pre-eclampsia patients (divided into early-onset [EOPE] and late-onset [LOPE] groups) and 74 controls from Ankara Etlik City Hospital. Doppler parameters-such as aortic isthmus flow index (IFI), systolic/diastolic ratio (S/D), pulsatility index (PI), and resistive index (RI)-were collected, and their associations with adverse perinatal outcomes were analyzed using ROC analysis.

RESULTS

In the EOPE group, gestational age, birth weight, and APGAR scores were significantly lower compared to the LOPE and control groups (p < 0.001). The EOPE group also showed significantly higher rates of NICU (neonatal intensive care unit) admission, preterm birth, respiratory distress syndrome, and need for mechanical ventilation (p < 0.001). The cut-off values for IFI (> 1.13) and AoI S/D (> 7.42) were found to be significant predictors of adverse perinatal outcomes.

CONCLUSION

AoI Doppler parameters may aid in predicting adverse neonatal outcomes in pre-eclampsia patients. The values of IFI, S/D, PI, and RI show potential as useful tools in clinical management, especially in monitoring high-risk pregnancies.

Peripartum fetal Doppler sonography and perinatal outcome: a systematic review and meta-analysis

OBJECTIVE

Systematically review and critically appraise the literature on the association between peripartum fetal Doppler sonography findings, i.e., acquired upon admission for spontaneous or induced labor, and perinatal outcome in term (37-42w) pregnancies.

METHODS

Medline, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov databases were systematically searched from inception to 05/2024. Studies conducted in unselected populations of term (37-42w) pregnancies, admitted for spontaneous or induced labor, reporting the association between fetal Doppler findings and perinatal outcome, were eligible for inclusion. Study eligibility was assessed independently by two reviewers. Methodological quality was assessed using the Quality In Prognosis Studies (QUIPS)-tool. Effect estimates were pooled using random-effects meta-analyses. Summary Odds Ratios (ORs) and Mean Differences (MDs) are reported with 95% confidence intervals.

RESULTS

Thirty-seven studies, reporting on 11.505 women and neonates, were included. Fourteen studies reported on findings from the umbilical artery (UA), four on the middle cerebral artery (MCA), five on the umbilical vein (UV), and nine on the cerebroplacental ratio (CPR). An abnormal UA Doppler and CPR increased the odds of fetal distress (FD) during labor (UA: OR 3.67 [1.14, 11.78], I2 = 72% - CPR: OR 3.19 [2.68, 3.80], I2 = 0%) and subsequent operative delivery (ODFD) (UA: OR 3.65 [1.66, 8.04], I2 = 81% - CPR: OR 2.48 [1.66, 3.70], I2 = 57%). Likewise, the presence of UV pulsations was strongly associated with both outcomes (FD: OR 28.78 [11.21, 73.87], I2 = 0% - ODFD: OR 303.36 [11.11, 8279.82], I2 = 0%). Regarding neonatal outcome, an Apgar-score < 7 at 5 min and NICU admission occurred more frequently if Doppler findings were abnormal in the UA (Apgar: OR 3.65 [1.82, 7.34], I2 = 0% - NICU: OR 3.92 [2.36, 6.51], I2 = 0%), or in case of an abnormal CPR (Apgar: OR 3.64 [2.03, 6.54], I2 = 0% - NICU: OR 2.71 [1.15, 6.38], I2 = 0%). Neonatal birthweight was also lower in the presence of an abnormal UA or CPR result, with a MD of -630.61g ([-1234.29, -26.93], I2 = 80%) and -146.52g ([-285.03, -8.01], I2 = 0%) respectively. Most studies (70.3%) were at high risk of bias on one or more domains; only 11 studies had an overall low risk of bias score.

CONCLUSION

Doppler sonography in the peripartum period allows for the identification of fetuses at risk of adverse birth outcomes. Further research on optimal thresholds to define at-risk cases and subsequent management strategies is needed.

PROSPERO REGISTRATION NUMBER

CRD42023413264.

Performance of ChatGPT and Microsoft Copilot in Bing in answering obstetric ultrasound questions and analyzing obstetric ultrasound reports

To evaluate and compare the performance of publicly available ChatGPT-3.5, ChatGPT-4.0 and Microsoft Copilot in Bing (Copilot) in answering obstetric ultrasound questions and analyzing obstetric ultrasound reports. Twenty questions related to obstetric ultrasound were answered and 110 obstetric ultrasound reports were analyzed by ChatGPT-3.5, ChatGPT-4.0 and Copilot, with each question and report being posed three times to them at different times. The accuracy and consistency of each response to twenty questions and each analysis result in the report were evaluated and compared. In answering twenty questions, both ChatGPT-3.5 and ChatGPT-4.0 outperformed Copilot in accuracy (95.0% vs. 80.0%) and consistency (90.0% and 85.0% vs. 75.0%). However, no statistical difference was found among them. When analyzing obstetric ultrasound reports, ChatGPT-3.5 and ChatGPT-4.0 demonstrated superior accuracy compared to Copilot (P < 0.05), and all three showed high consistency and the ability to provide recommendations. The overall accuracy and consistency of ChatGPT-3.5, ChatGPT-4.0, and Copilot were 83.86%, 84.13% vs. 77.51% in accuracy, and 87.30%, 93.65% vs. 90.48% in consistency, respectively. These large language models (ChatGPT-3.5, ChatGPT-4.0 and Copilot) have the potential to assist clinical workflows by enhancing patient education and patient clinical communication around common obstetric ultrasound issues. With inconsistent and sometimes inaccurate responses, along with cybersecurity concerns, physician supervision is crucial in the use of these models.

Value of cerebroplacental ratio in predicting adverse perinatal outcome in uncomplicated twin pregnancies: a retrospective study

To evaluate the performance of the cerebroplacental ratio (CPR) in predicting operative delivery for intrapartum fetal compromise (OD for IFC) and adverse perinatal outcomes in uncomplicated twin pregnancies with attempted vaginal delivery.This was a retrospective cohort study of 72 twin pregnancies in a single tertiary referral center between January 2018 and August 2024. All MCDA and DCDA twin pregnancies with an attempted vaginal delivery after 34+0 weeks were screened for eligibility and those without further risk factors were included in the study. Outcome parameters were OD for IFC and a composite of adverse perinatal outcomes (CAPO) including OD for IFC, 5-minute Apgar score <7, umbilical artery pH <7.10, or admission to the neonatal intensive care unit (NICU). The predictive performance of CPR was evaluated using ROC analyses and multivariable logistic regression.16 MCDA and 56 DCDA pregnancies met the inclusion criteria. CAPO of at least one of the twins occurred in 27 (37.5%) of the cases. ROC analyses showed that low CPR MoM of neither the presenting twin nor the second twin predicted CAPO. Similarly, the prediction of the need for OD for IFC of twin 2 was not possible using low CPR MoM as the predicting variable. However, logistic regression analyses showed that nulliparity and twin-to-twin delivery time interval were independently associated with CAPO.Low CPR MoM was not predictive for CAPO or OD for IFC in uncomplicated twin pregnancies after 34 weeks of gestation. However, nulliparity and twin-to-twin delivery time interval were independently associated with CAPO.

Maternal oxygen inhalation affects the fetal hemodynamic in low-risk with uncomplicated late pregnancy

BACKGROUND

Maternal oxygen inhalation during labor has not been shown to provide significant benefits to newborns. However, its impact on fetal hemodynamics in late pregnancy remains uncertain.

OBJECTIVE

This study aimed to investigate the association between maternal oxygen inhalation in the late trimester and changes in fetal hemodynamics. Specifically, we assessed the short-term effects of maternal oxygen administration on fetal Doppler parameters and evaluated whether this practice has potential benefits or risks for the fetus.

STUDY DESIGN

These retrospective data were obtained from singleton pregnancies who underwent a after 32+0 weeks prenatal ultrasound examination between January 2022 and December 2022. Participants were categorized into oxygen inhalation and non-oxygen inhalation groups. Oxygen inhalation was administered based on maternal request, primarily due to concerns about hypoxia from prolonged mask use during the COVID-19 pandemic, rather than clinical indication. Our study analysis was performed in August 2023. In oxygen inhalation group, pregnant women received oxygen inhalation with 3 L/min for 30 min by nasal cannula, and before went to department of ultrasound for sonographic assessment within 1 h. The CPR and PPI were predefined as primary outcomes prior to analysis. Each woman was recorded Doppler index and calculated placental pulsatility index (PPI) and cerebroplacental ratio (CPR). Moreover, fetal cardiac function was assessed within pulsed Doppler or M-mode.

MAIN OUTCOME

The primary outcome presented higher PPI, lower CPR, and lower birth weight for the exposure maternal oxygen inhalation group, compare to non-oxygen inhalation group.

RESULTS

A total of 104 singleton pregnancies were included in the final analysis (oxygen inhalation group: n = 48). No significant differences were observed in the resistance indices of the uterine arteries, umbilical arteries, middle cerebral arteries, descending aorta, ductus venosus, or umbilical vein. However, variations were noted in the oxygen inhalation group. Notably, indices with higher sensitivity for predicting adverse outcomes demonstrated significant differences between groups: PPI was higher in the oxygen inhalation group compared to the non-oxygen inhalation group (0.81 ± 0.12 vs. 0.76 ± 0.11, p < .05), while CPR was also lower in the oxygen inhalation group (1.98 ± 0.56 vs. 2.28 ± 0.70, p < .05). Additionally, birth weight was significantly lower in the oxygen inhalation group compared to the non-oxygen inhalation group (2983.78 ± 468.18 g vs. 3178.41 ± 477.59 g, p < .05).

CONCLUSION

Our study found that brief maternal oxygen inhalation in the third trimester was associated with significant changes in fetal hemodynamics, specifically higher PPI and lower CPR. Both of these indices are sensitive markers of unfavorable prenatal outcomes, indicating that maternal oxygen inhalation may adversely affect fetal health. These findings underscore the importance of carefully evaluating the use of oxygen inhalation in pregnant women, especially those in high-risk pregnancies. Additionally, monitoring Doppler indices before and after oxygen administration may help assess fetal well-being and guide clinical decision-making in these situations.

Relationship Between Adverse Neonatal Outcomes and Diastolic Deceleration Area on Fetal MCA Doppler in Patients with Late Fetal Growth Restriction

Objectives

This study aimed to assess the predictive value of the Diastolic Deceleration Area (DDA), a novel Doppler ultrasound parameter, in detecting adverse neonatal outcomes in fetuses with late-onset fetal growth restriction (FGR). While Doppler parameters such as cerebroplacental ratio (CPR), umbilicocerebral ratio (UCR), and cerebralplacentaluterine ratio (CPUR) are commonly used for fetal monitoring, their predictive power varies. Given the importance of cerebral blood flow redistribution in fetal adaptation to hypoxia, we investigated whether DDA could serve as a reliable indicator of fetal distress and adverse perinatal outcomes.

Methods

This prospective case-control study was conducted between January 2024 and July 2024, including 90 pregnant women: 45 diagnosed with late-onset FGR and 45 gestational age-matched healthy controls. Doppler ultrasound measurements, including umbilical artery, uterine artery, middle cerebral artery Doppler indices, CPR, UCR, CPUR, and DDA, were performed. The primary outcome was the prediction of adverse neonatal events, such as neonatal intensive care unit (NICU) admission, neonatal sepsis, respiratory distress, low APGAR scores, and low cord blood pH. Receiver Operating Characteristic (ROC) curve analysis was used to determine the predictive ability of the Doppler indices.

Results

DDA values were significantly higher in the FGR group compared to controls (p<0.001). At a cut-off value of >7.23, DDA demonstrated 50% sensitivity and 88% specificity, making it the most specific Doppler parameter for predicting adverse neonatal outcomes. In comparison, CPR (cut-off ≤2.11), UCR (cut-off >0.46) and CPUR (cut-off ≤1.36) had higher sensitivity (96%, 96%, 54%) but lower specificity (32%, 31% and 85% respectively).

Conclusion

DDA is a promising Doppler parameter for identifying fetuses at risk in late-onset FGR. Its high specificity suggests it could be a valuable supplementary tool alongside traditional Doppler indices for better risk assessment and clinical decision-making. Further studies are needed to validate its role in perinatal care.

Fetal Doppler assessment in pregnancy

Fetal Doppler assessment plays a crucial role in monitoring the fetal well-being during pregnancy. This non-invasive technique assesses blood flow dynamics in key fetal vessels, namely the umbilical artery, middle cerebral artery, and ductus venosus. The umbilical artery Doppler provides valuable insights into placental function aiding in the early detection of fetal growth restriction and fetal distress. Assessment of the middle cerebral artery Doppler provides information on the adequacy of cerebral perfusion. It is highly sensitive to changes in fetal oxygenation and contributes to the management of advanced stages of early fetal growth restriction. It is also a valuable and sometimes standalone marker for late-term fetal hypoxic compromise and fetal anemia. Doppler evaluation of ductus venosus offers additional data for identifying cardiac compromise and predicting adverse perinatal outcomes. Incorporating these Doppler assessments into routine prenatal care enhances the ability to detect and manage fetal compromise, ultimately improving pregnancy outcomes.

Association between deep learning radiomics based on placental MRI and preeclampsia with fetal growth restriction: A multicenter study

PURPOSE

Preeclampsia (PE) is associated with placental insufficiency and could lead to adverse pregnancy outcomes. The study aimed to develop a placental T2-weighted image-based automatic quantitative model for the identification of PE pregnancies and disease severity.

METHODS

Between July 2013 and September 2022, the retrospective multicenter study featured 420 pregnant women, including 140 cases of PE and 280 cases of normotensive pregnancies. The semi-supervised approach was used to gain an automatic segmentation for placental MRI. The radiomics, deep learning, and deep learning radiomics (DLR) models were built.

RESULTS

In PE pregnancies, 65 (46.4 %) fetuses developed PE with fetal growth restriction (FGR), and 75 (53.6 %) cases were PE without FGR. The Dice of semi-supervised placental segmentation was 0.917. The AUCs of the DLR signature for discriminating PE pregnancies from normotensive pregnancies were 0.839 (95 % CI: 0.793-0.886), 0.858 (95 % CI: 0.742-0.974), 0.888 (95 % CI: 0.783-0.992), and 0.843 (95 % CI: 0.731-1.000) in the training, test, internal validation, and external validation sets, respectively. This DLR analysis model performed well in discriminating between PE with FGR and normotensive pregnancies (AUC = 0.918, 95 % CI: 0.879-0.957) and PE without FGR (AUC = 0.742, 95 % CI: 0659-0.824).

CONCLUSION

The automatic radiomics analysis has been developed to identify PE pregnancies by determining DLR features on placental T2-weighted images, and to predict FGR exposed to PE.

Reproducibility of fetal ultrasound doppler parameters used for growth assessment

OBJECTIVES

To produce standards of references for quality control and assess the reproducibility of fetal ultrasound Doppler measurements commonly used for blood flow assessment in fetal growth.

METHODS

Women with singleton normal pregnancies were prospectively recruited at University College London Hospital, UK, between 24 and 41 weeks. Umbilical artery (UA), middle cerebral artery (MCA), and their pulsatility indices (PI), resistance indices (RI) and ratios such as cerebro-placental (CPR) and umbilical cerebral ratio (UCR) were obtained twice by two sonographers in training or after completion of training, blind to each other's measurements. Bland-Altman plots were generated, the mean differences and 95% limits of agreement (LOA) were calculated to assess intra- and interobserver reproducibility. Values were expressed as absolute values or as z-score.

RESULTS

One hundred ten women were recruited. Overall reproducibility was variable for absolute values and highly variable for z-scores, independently from vessel sampled, index or ratio used, intra- or interobserver reproducibility. The widest absolute values of 95% LOA were 0.3 for UA PI, 0.7 for MCA PI, 0.9 for CPR and 0.3 for UCR, respectively. Regarding z-score, the widest 95% LOA were 1.9 for UA PI, 2.1 for CPR and 1 for UCR. Reproducibility was slightly better for intra- compared with interobserver variability. There was significant difference in z-score reproducibility between MCA peak systolic velocity and CPR vs UCR.

CONCLUSIONS

Reference standards of reproducibility of fetal Doppler parameters are produced for standardization and quality-control purposes. Overall, the reproducibility for fetal Doppler parameters was variable independently from vessel sampled, Doppler index (PI or RI) or ratio used, intra- and interobserver comparison. UCR was the most reproducible parameter which should be recommended, together with UA PI, for clinical use and in research studies on fetal growth.

Angiogenic factors alone or in combination with ultrasound Doppler criteria for risk classification among late-onset small fetuses with or without pre-eclampsia

OBJECTIVE

To investigate the prognostic value of maternal angiogenic factors in late-onset small fetuses, alone or in combination with the ultrasound and Doppler parameters currently used for the classification of low-risk small-for-gestational-age (SGA) fetuses or high-risk fetal growth restriction (FGR), overall and according to the presence or absence of pre-eclampsia.

METHODS

This was a prospective cohort study of women with a singleton pregnancy with a diagnosis of late-onset fetal smallness (defined as birth weight < 10th centile) and a gestational age of ≥ 34 weeks at delivery. Ultrasound assessment of estimated fetal weight (EFW) and Doppler assessment of uterine artery pulsatility index (UtA-PI) and cerebroplacental ratio (CPR) were performed every 1-2 weeks. Biochemical analysis of the angiogenic factors placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) in maternal peripheral venous blood samples was performed using enzyme-linked immunosorbent assay within 1-2 weeks after diagnosis of SGA or FGR. The primary outcome was adverse perinatal outcome, defined as a composite of emergency Cesarean section for non-reassuring fetal status, metabolic acidosis (umbilical artery pH < 7.0), neonatal unit admission and/or perinatal death. The predictive value of EFW < 3rd centile, Doppler parameters (UtA-PI > 95th centile and CPR < 5th centile) and sFlt-1/PlGF ratio > 95th centile, alone or in combination, was assessed using logistic regression analysis in the overall population and stratified by presence or absence of pre-eclampsia developing at any time before delivery.

RESULTS

Among the 602 included cases, 91 (15.1%) developed pre-eclampsia and 511 (84.9%) did not. In the overall study population, all parameters were associated independently with adverse perinatal outcome: EFW < 3rd centile (adjusted odds ratio (aOR), 2.58 (95% CI, 1.67-4.00)), UtA-PI > 95th centile (aOR, 1.92 (95% CI, 1.25-2.94)), CPR < 5th centile (aOR, 2.35 (95% CI, 1.46-3.78)) and sFlt-1/PlGF ratio > 95th centile (aOR, 1.71 (95% CI, 1.09-2.69)). Only sFlt-1/PlGF ratio > 95th centile was associated independently with adverse perinatal outcome in cases with pre-eclampsia, whereas in those without pre-eclampsia, only EFW < 3rd centile and CPR < 5th centile were associated independently with adverse perinatal outcome. In the overall population, the detection rate (DR) and false-positive rate for adverse perinatal outcome were, respectively: 39.8% (95% CI, 31.7-47.9%) and 16.9% (95% CI, 10.7-23.1%) for sFlt-1/PlGF ratio > 95th centile alone; 86.8% (95% CI, 83.4-90.2%) and 61.9% (95% CI, 57.1-66.7%) for a combined model of EFW < 3rd centile, UtA-PI > 95th centile and CPR < 5th centile; 81.3% (95% CI, 77.3-85.3%) and 52.3% (95% CI, 47.1-57.5%) for a combined model of EFW < 3rd centile and sFlt-1/PlGF ratio > 95th centile; and 88.5% (95% CI, 85.4-91.6%) and 64.5% (95% CI, 59.8-69.2%) for a combined model including all the abovementioned observed parameters.

CONCLUSIONS

sFlt-1/PlGF ratio alone had a low predictive value for adverse perinatal outcome, but when combined with EFW, its predictive performance was similar to that of EFW combined with Doppler parameters. Combining sFlt-1/PlGF ratio with EFW and Doppler criteria achieved the highest DR for adverse perinatal outcome, and additionally, might help to identify imminent pre-eclampsia in pregnancies complicated by fetal smallness. These findings support the use of angiogenic factors as an additional criterion to those currently used for identifying high-risk FGR among late-onset small fetuses, but do not support their use as a standalone biomarker. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Vertebroplacental ratio for prediction of perinatal outcome and operative delivery for suspected fetal compromise: prospective observational cohort study

OBJECTIVE

To investigate differences in fetal vertebroplacental ratio (VPR) depending on the occurrence of operative delivery for suspected fetal compromise (ODFC) and composite perinatal outcome (CPO) at delivery.

METHODS

This was a prospective observational cohort study conducted in the Department of Obstetrics and Gynecology at the University Hospitals of Leuven, Leuven, Belgium, between December 2022 and April 2024. Women with a term (37-42 gestational weeks) singleton pregnancy with an appropriate-for-gestational-age (AGA) fetus were recruited, before cervical dilatation reached 5 cm, for sonographic fetal weight estimation (EFW) and Doppler sonography of the umbilical artery (UA), umbilical vein (UV), middle cerebral artery (MCA) and vertebral artery (VA). The primary outcomes were differences in VPR multiples of the median (MoM) depending on the occurrence of ODFC and CPO at delivery (based on UA cord blood pH and base excess, 1-min and 5-min Apgar score, and neonatal intensive care unit admission). We explored the technical feasibility of fetal Doppler sonography in this setting and differences in Doppler findings from individual fetal vessels (UA, UV blood flow (UVF), MCA, VA) and related parameters (UVF/EFW and cerebroplacental ratio (CPR)). We also investigated whether adding individual sonographic variables to baseline clinical prediction models could improve discriminatory power (using the area under the receiver-operating-characteristics curve (AUC)) and predictive accuracy (using the Brier score) for both outcomes.

RESULTS

A total of 161 women were recruited. The mean ± SD maternal age was 32.2 ± 3.8 years and approximately half (53.4%) of the women were nulliparous. Most (88.2%) women had labor induced. The mean ± SD gestational age at delivery was 39.3 ± 1.0 weeks and the mean ± SD ultrasound-to-delivery interval was 10.4 ± 2.75 h. An adverse CPO occurred in 13.3% of cases and ODFC occurred in 17.4%. No difference in mean VPR MoM was observed between cases with normal vs adverse CPO (1.04 ± 0.26 vs 1.17 ± 0.25; P = 0.09), or between cases which underwent ODFC vs those which did not (1.06 ± 0.29 vs 1.06 ± 0.26; P = 0.97). Likewise, no differences in other Doppler variables (UA pulsatility index (PI) MoM, MCA-PI MoM, VA-PI MoM, CPR MoM) were observed for both outcomes, except for significantly higher UVF rates in the adverse CPO group (both absolute (P = 0.02) and corrected for EFW (P = 0.048)). For both outcomes, adding VPR MoM or any other sonographic variable to baseline prediction models, which consisted solely of clinical variables, did not improve predictive accuracy or discriminatory power. The baseline model AUC and Brier score values were 0.68 (95% CI, 0.57-0.79) and 0.14 for adverse CPO, and 0.72 (95% CI, 0.61-0.83) and 0.13 for ODFC, respectively.

CONCLUSIONS

Although technically feasible to measure in most women with an AGA fetus admitted for spontaneous or induced labor at term, no difference in VPR MoM was observed depending on the occurrence of ODFC or CPO at delivery. Moreover, adding VPR MoM or any other sonographic variable to a baseline clinical prediction model did not improve predictive accuracy or discriminatory power for either outcome. Hence, peripartum ultrasound for the assessment of fetal weight and placental function has limited added value for predicting adverse labor outcomes in a low-risk obstetric population. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.

Multiparametric ultrasound (MPUS) evaluation of the testes of normozoospermic dogs - a pilot study

Ultrasound is an important tool in small animal andrology for assessing the integrity of the testes. This study explores ultrasound's role in assessing the canine testes and understanding the correlation of sonographic parameters to sperm quality. It investigates B-mode and Doppler ultrasound techniques alongside advanced methods like Shear-wave Elastography (SWE) and Contrast-enhanced ultrasound (CEUS). The aim was to standardize a multiparametric ultrasound (MPUS) evaluation protocol using these techniques in normozoospermic dogs. Eight healthy male dogs were assessed. B-mode assessed testicular morphology, while Doppler evaluated testicular artery waveform morphology and velocimetric parameters. SWE measured testicular stiffness, and CEUS assessed testicular perfusion. Seminal parameters were also analyzed. Results revealed normal B-mode sonographic findings and some correlations between Doppler parameters and sperm quality. SWE demonstrated consistent testicular stiffness regardless of the depth of evaluation, with correlations of the stiffness of the head of the epididymis to the ejaculate volume. CEUS identified blood flow differences between testes and some perfusion parameters correlated with sperm features. This comprehensive ultrasound assessment provides valuable insights into canine reproductive health, providing basis for further studies on dogs with abnormal sperm quality and with different fertility statuses.

Clinical application of the quantitative fetal heart quantification in the evaluation of right heart function in fetuses with redundancy foramen ovale flap

BACKGROUND

To investigate the clinical value of fetal heart quantification (fetal HQ) in the evaluation of right ventricular size, morphology and cardiac function in fetuses with redundancy foramen ovale flap (RFOF).

METHODS

31 fetuses diagnosed with RFOF through echocardiography from September 2021 to December 2023 were selected as the control group, and 62 healthy fetuses that matched the age and gestational period of the pregnant women in the RFOF group were chosen as the control group. Fetal HQ software provided by GE Voluson E10 was employed to automatically track endocardial parameters of the right ventricle in 24 segments.

RESULTS

The internal diameter of foramen ovale in RFOF group was significantly smaller than that of normal fetal diameter in control group, with statistical significance (P < 0.05). Comparing the morphological parameters of the fetuses in the RFOF group and the control group, there was no statistically significant difference in the GSI scores (P > 0.05), but the RV-LED of the fetuses in the RFOF group in the segments of 1-24 were higher than the fetuses in the normal control group (both P < 0.05), and the RV-SI was lower than that in the normal control group (all P < 0.05).

CONCLUSIONS

The Fetal HQ technique enables accurate localisation of the site of the RFOF foetal lesion by rapid quantitative analysis of morphological and functional parameters of the right ventricle of the foetal heart.

A nomogram for predicting adverse perinatal outcome with fetal growth restriction: a prospective observational study

BACKGROUND

Fetal growth restriction (FGR) is a major determinant of perinatal morbidity and mortality. Our study aimed to develop a prediction model for the risk of FGR developing adverse perinatal outcome (APO) and evaluate its performance.

METHODS

This was a prospective observational cohort study of consecutive singleton gestations meeting the ACOG-endorsed criteria for FGR from January 2022 to June 2023 at Obstetrics and Gynecology Hospital of Fudan University. Clinical information, ultrasound indicators and serum biomarkers were collected. The primary composite APO comprised one or more of: perinatal death, intrauterine demise, intraventricular hemorrhage, periventricular leukomalacia, seizures, necrotizing enterocolitis, neonatal respiratory distress syndrome, sepsis and the length of stay in the neonatal intensive care unit > 7 days. Least absolute shrinkage and selection operator regression was used to screen variables for nomogram model construction. The discrimination, calibration and clinical effectiveness of the nomogram were evaluated using receiver operating characteristic curve, calibration plots and decision curve analysis in training and validation cohorts.

RESULTS

A total of 122 pregnancies were enrolled in the final statistical analysis. Five variables were identified to establish a nomogram, including gestational weeks at diagnosis, abnormal umbilical artery Doppler, abnormal uterine artery Doppler, and multiples of the median values of placental growth factor and soluble fms-like tyrosine kinase-1. The area under the receiver-operating-characteristics curve of 0.87 (95% CI, 0.75-0.99) and 0.86 (95% CI, 0.74-0.98) in the training and validation cohort respectively, indicated satisfactory discriminative ability of the nomogram. The calibration plots showed favorable consistency between the nomogram's predictions and actual observations. Decision curve analysis supported its practical value in a clinical setting.

CONCLUSIONS

A nomogram was developed and validated to possess the promising capacity of predicting APO in FGR-afflicted neonates, and may prove useful in counseling and management of pregnancies complicated by FGR.

Cerebroplacental Ratio Versus Umbilicocerebral Ratio in Predicting Adverse Neonatal Outcomes: A Prospective Observational Study

Background

Antenatal identification of "at risk" fetuses is crucial for timely intervention to aid in achieving better perinatal outcomes. One such means is the use of Doppler for fetal hemodynamic monitoring. Using the same our study aimed to compare the utility of two Doppler parameters, Cerebroplacental ratio (CPR) and Umbilicocerebral ratio (UCR), in predicting adverse neonatal outcomes.

Methods

A total of 280 antenatal women participated in a prospective observational study following 28 weeks of gestation, and CPR and UCR (inverse of CPR) were determined by serial Doppler ultrasound. This was converted to gestational age-specific percentiles and Z-scores using Fetal Medicine Foundation (FMF) as a reference for CPR and study by Acharya et al. for UCR.

Results

Out of the 277 participants analyzed, abnormal Doppler parameters were present in 27 (9.7%) women. The abnormal Doppler group had a considerably greater occurrence of adverse outcomes, including Apgar score < 7 at 1 min, small for dates, neonatal hypoglycemia, requirement of ventilatory support, prolonged hospitalization, NICU (Neonatal intensive care unit) admission, and a composite of adverse outcomes. ROC (Receiver operating characteristic) curves exhibited an AUC (Area Under the Curve) of 0.76 for both CPR and UCR and a slightly higher AUC of 0.83 and 0.85 for their centiles and Z-scores, respectively.

Conclusion

Both CPR and UCR Doppler parameters are no different from each other in predicting adverse neonatal outcomes. The same holds true even on conversion to gestational age-specific centiles and Z-scores.

Ultrasonographic assessment of the fetal heart in intrahepatic cholestasis of pregnancy: Pulsed wave Doppler, M-mode, and tissue Doppler imaging prospective study

OBJECTIVES

To investigate the fetal heart using pulsed wave Doppler, M-mode, and tissue Doppler imaging (TDI) in cases of intrahepatic cholestasis of pregnancy (ICP).

METHODS

This prospective study was conducted at a single tertiary center and included 35 patients with ICP and 70 healthy pregnant women at 28-36 weeks of pregnancy. Among the patients with ICP, 26 had serum bile acid (SBA) levels less than 40 μmol/L and nine had SBA levels of 40 μmol/L or greater. Pulsed wave Doppler, M-mode, and TDI evaluations were performed on the patients to assess fetal cardiac function.

RESULTS

The ICP group exhibited significantly higher myocardial performance index (MPI) and isovolumetric relaxation time (IRT), but similar isovolumetric contraction time (ICT). The tricuspid and mitral valve E, A, and E/A ratios were significantly reduced in the ICP group. The TDI parameters showed significantly reduced tricuspid and mitral valve E'/A' ratios in the ICP group compared with the control group (P < 0.001). The E/E' ratio was significantly increased in the ICP group (P < 0.001). According to the M-mode Doppler findings, tricuspid and mitral annular plane systolic excursion values were significantly decreased in the ICP group (P = 0.005 and P = 0.001, respectively). In the subgroup analysis, MPI and IRT were significantly higher in the severe ICP group.

CONCLUSION

ICP might induce changes in the fetal heart during the early systolic and diastolic phases. The detection of these early changes using M-mode and TDI during the antenatal period can provide valuable insights into the condition of the fetus.

Evaluation of Conventional and Combined Doppler Parameters in Preeclampsia: Diagnostic and Prognostic Insights

Background: The aim of this study was to examine the relationship between conventional and novel Doppler parameters, including cerebroplacental ratio (CPR), cerebral-placental-uterine ratio (CPUR), umbilical-to-cerebral ratio (UCR), and amniotic-to-umbilical-cerebral ratio (AUCR), with the diagnosis of preeclampsia (PE) and adverse neonatal outcomes in PE cases. Methods: This prospective case-control study was conducted at the Ankara Etlik City Hospital Perinatology Clinic between November 2023 and May 2024. The study population was divided into two groups: Group 1, consisting of 74 patients diagnosed with preeclampsia, and Group 2, consisting of 80 healthy control patients. Composite adverse perinatal outcomes (CANOs) include presence of at least one adverse outcome: 5th-minute APGAR score < 7, transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), need for continuous positive airway pressure (CPAP), need for mechanical ventilation, neonatal intensive care unit (NICU) admission, neonatal hypoglycemia, need for phototherapy, intraventricular hemorrhage (IVH), and neonatal sepsis. Results: The CPR, CPUR, and AUCR were significantly lower in the PE group compared to the control group, while the UCR was notably higher in the PE group. Among the combined ratios, the CPUR exhibited the highest diagnostic performance for both PE diagnosis and the prediction of CANOs. Additionally, while the UCR, CPR, and AUCR were significant for PE diagnosis, only AUCR demonstrated a significant association with the prediction of CANOs. Conclusions: Combined Doppler parameters, especially CPUR and AUCR, offer valuable insights into diagnosing PE and predicting CANOs. CPUR demonstrated the highest diagnostic accuracy, underscoring its potential utility in clinical settings.

Effect of abnormal placental cord insertion on hemodynamic change of umbilical cord in a tertiary center: a prospective cohort study

BACKGROUND

Our study aims to evaluate the umbilical vein (UV) hemodynamic change in the prenatal cohort of pregnancies diagnosed with abnormal placental cord insertion (aPCI).

METHODS

From January 2022 to December 2022, the fetal umbilical cord insertion site was sonographically examined in singleton fetuses, and umbilical cord blood flow was calculated. The umbilical artery and UV Doppler flow indexes were assessed in cases of normal and abnormal cord insertion.

RESULTS

Among 570 singleton fetuses between 18 + 0 and 40 + 6 weeks of gestation in the final study, the umbilical vein blood flow (UVBF) in the 3 groups of normal umbilical cord insertions, marginal umbilical cord insertions, and velamentous umbilical cord insertions was 145.39 ml/min, 146.18 ml/min, and 93.96 ml/min, respectively. UVBF was significantly lower in the velamentous cord insertion (VCI) group than in the other groups (P < 0.05). Compared with the normal cord insertions group, lower birth weight (2820 ± 527 g vs. 3144 ± 577 g, P < 0.05), delivery at an earlier gestational age (38.0 ± 1.55 weeks vs. 38.8 ± 2.34 weeks, P < 0.05), higher bicarbonate (25.08 ± 1.72 mmol/L vs. 22.66 ± 4.05 mmol/L, P < 0.05), and higher standard base excess (-1.14 ± 1.50 mmol/L vs. -3.30 ± 3.22 mmol/L, P < 0.05) were found in the VCI group.

CONCLUSIONS

We observed lower UVBF volume with aPCI. Hence, we propose UVBF analysis to evaluate fetal aPCI according to UV hemodynamics as an advisory in prenatal care. This would be useful and improve obstetricians' clinical explanation about the potential prenatal consequences so that parents can opt for future prenatal care during pregnancy.

The role of umbilical vein blood flow assessment in the prediction of fetal growth velocity and adverse outcome: a prospective observational cohort study

BACKGROUND

Identifying fetal growth restriction and distinguishing it from a constitutionally small fetus can be challenging. The umbilical vein blood flow is a surrogate parameter of the amount of oxygen and nutrients delivered to the fetus, providing valuable insights about the function of the placenta. Nevertheless, currently, this parameter is not used in the diagnosis and management of fetal growth restriction.

OBJECTIVE

To evaluate the umbilical vein blood flow and fetal growth velocity in small for gestational age fetuses and in fetal growth restriction, and to evaluate their capacity to predict adverse perinatal outcome and iatrogenic preterm birth. Secondly, to assess the correlation between umbilical vein blood flow and fetal growth velocity.

STUDY DESIGN

This was a prospective multicentric observational cohort study of women with a diagnosis of small for gestational age or fetal growth restriction in which fetal biometry and Doppler assessment, including umbilical vein blood flow measurement, were performed. The fetal growth velocity was derived from the difference between the estimated fetal weight calculated in 2 consecutive sonographic evaluations. The pregnancies were followed until delivery. Between-group differences were evaluated, and Pearson or Spearman correlation coefficients were reported to assess the relationship between variables of interest. Optimal cutoffs on the resulting receiver operating characteristic curve were determined and used to predict the outcomes of interest. Simple and multiple logistic regression models were estimated using umbilical vein blood flow and fetal growth velocity to predict adverse perinatal outcomes and iatrogenic preterm birth.

RESULTS

The study population included 64 small for gestational age and 58 growth restricted fetuses. When compared to reference ranges, small for gestational age fetuses had significantly lower fetal growth velocity and umbilical vein blood flow (P<.001). When compared to small for gestational age, fetuses with growth restriction had lower umbilical vein blood flow (P<.001), umbilical vein blood flow corrected for estimated fetal weight and abdominal circumference (P<.01 and P<.001), and fetal growth velocity (P<.001). Fetal growth velocity was positively correlated with umbilical vein blood flow (r=0.46, P<.001). The multivariable logistic regression analyses showed that, after adjusting for diagnosis of fetal growth restriction, umbilical vein blood flow ≤0.65 multiple of the median (adjusted odds ratio [aOR] 3.5; 95% confidence interval [CI] 1.0-11.8) and fetal growth velocity ≤0.63 multiple of the median (adjusted odds ratio 3.0, 95% CI 1.2-7.9) were associated with adverse perinatal outcome. Furthermore, when accounting for fetal growth restriction diagnosis, umbilical vein blood flow ≤0.60 multiple of the median (adjusted odds ratio 5.2, 95% CI 1.7-15.9), and fetal growth velocity ≤0.63 multiple of the median (adjusted odds ratio 3.6, 95% CI 1.1-12.6) were significant predictors of iatrogenic preterm birth.

CONCLUSION

Umbilical vein blood flow could play a role to identify fetuses with fetal growth restriction and to predict fetal growth at the subsequent biometric evaluation. We found a significant correlation between umbilical vein blood flow and fetal growth. Umbilical vein blood flow and fetal growth velocity are independent predictors of iatrogenic preterm birth and adverse perinatal outcome in a population of small fetuses, regardless of the Delphi consensus criteria. These results support future study on the predictive value of this parameter in fetuses with a suspected fetal growth restriction.

Comparison of umbilical artery pulsatility index reference ranges

OBJECTIVE

To compare the accuracy of four published reference standards for the umbilical artery pulsatility index (UA-PI) in predicting small-for-gestational age (SGA), adverse neonatal outcomes and obstetric complications in pregnancies at risk for fetal growth restriction.

METHODS

This was a secondary analysis of a prospective study of singleton pregnancies that underwent fetal growth assessment by ultrasound between 26 and 36 weeks' gestation. Pregnancies with estimated fetal weight or abdominal circumference < 20th percentile with UA-PI measurements available were included. We excluded fetuses with chromosomal anomaly or congenital malformation and those without delivery information. The predictive ability of UA-PI > 95th percentile according to the reference standards of Acharya et al., the INTERGROWTH-21st Project, the Fetal Medicine Foundation and Parra-Cordero et al. for SGA, a composite of adverse neonatal outcomes and a composite of obstetric complications was compared using the area under the receiver-operating-characteristics curve (AUC). Sensitivity, specificity and positive and negative predictive values were calculated.

RESULTS

Of the 1054 pregnancies that underwent fetal growth evaluation by ultrasound, 207 were included in our analysis. SGA, adverse neonatal outcomes and obstetric complications were diagnosed in 94 (45.4%), 50 (24.2%) and 69 (33.3%) cases, respectively. All reference standards had similar and statistically significant but poor predictive accuracy for SGA (AUC of 0.55 to 0.56), adverse neonatal outcomes (AUC of 0.57 to 0.60) and obstetric complications (AUC of 0.55 for all).

CONCLUSIONS

The reference standards for UA-PI evaluated herein have poor predictive ability for SGA, adverse neonatal outcomes and obstetric complications. At present, no particular UA-PI reference standard can be recommended over others. Larger trials are needed to answer this research question. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

A comparison of the effects of nifedipine and indomethacin used in preterm labor tocolytic treatment on feto-maternal Doppler ultrasonography flow

OBJECTIVE

To compare the effects of nifedipine and indomethacin, used for tocolytic purposes in the treatment of preterm labor (PTL), on fetal-maternal Doppler blood flows and perinatal outcomes.

MATERIALS AND METHODS

Eighty pregnant women between weeks 24 and 32 of gestation who used nifedipine (n = 40) and indomethacin (n = 40) as tocolytic treatments due to PTL were prospectively and consecutively included in the study. Sociodemographic, obstetric, and laboratory and Doppler flow parameters were compared between the groups.

RESULTS

Statistically significant differences were observed between the groups in terms of gestational age at delivery and birth weight, Doppler flows (umbilical artery (UA) Pulsatility Index (PI), and UA Resistance Index (RI)) at 12, 24, and 48 h, middle cerebral artery RI at 12 h, and ductus venosus (DV) PI and DV-RI at 12, 24, and 48 h (p < 0.05).

CONCLUSIONS

The findings of this study showed that nifedipine and indomethacin used in the treatment of PTL had significant effects on UA-PI and UA-RI Doppler flows at 12, 24, and 24 h, MCA-RI Doppler flows at 12 h, and DV-PI and DV-RI Doppler flows at 12, 24, and 48 h. Further studies involving larger numbers of participants are now needed to support these results.

Impact of Sonographer Experience, Insonation Angle, and Bladder Filling on Uterine Artery Doppler Measurements in the First Trimester of Pregnancy

OBJECTIVE

To investigate the influence of different measurement conditions and ultrasound training level on uterine artery pulsatility index (UtA-PI) measurements as required for combined first trimester preeclampsia (PE) screening.

METHODS

This was a prospective study of consecutive patients with singleton pregnancies presenting for an ultrasound examination between 11 and 14 weeks' gestation. UtA-PI measurements were conducted by residents in training and repeated by experienced sonographers thereafter. UtA-PI measurements were conducted under different examination conditions. First, the trainee sonographers performed transabdominal sagittal and transverse UtA-PI measurements without bladder filling. These measurements were then repeated by the expert sonographers. Additionally, the expert sonographers also performed transvaginal UtA-PI measurements and transabdominal measurements with bladder filling. Statistical analysis was conducted with the statistical software R and included descriptive statistics as well as 2-sided paired t tests.

RESULTS

A total of 100 women were included in the study. Mean age was 31.7 ± 4.92 years and mean gestational week was 12.5 ± 0.53 weeks. A total of 56% were nulliparous and 44% were parous. UtA-PI was significantly lower if performed by a sonographer in training versus an experienced sonographer (P = .031). No significant difference was observed in comparing transverse and sagittal techniques (P = .241). There was also no significant difference in transabominal versus transvaginal measurements (P = .806) and with an empty versus full bladder (P = .444).

CONCLUSION

Experience of sonographer has a significant impact on UtA-PI. Supervised onsite training is necessary to improve reliability and consistency of UtA-PI measurements and make PE screening reliable for implementation in a universal screening setting.

Arterial and Venous Doppler in Evaluation of the "At-risk" Fetus

Our practice utilizes Doppler ultrasound as one of the most objective and effective methods to assess at-risk pregnancies. This review will discuss the application of arterial and venous Doppler techniques in assessing and managing various diseases and conditions for high-risk fetuses.

Is Averaging of Three Waveforms Sufficient to Generate a Truly Representative Value for Pulsed-Wave Doppler Measures of Impedance?

OBJECTIVE

We aimed to evaluate the physiological variation in common pulsed-wave Doppler (PWD) indices of impedance to determine the number of waveforms to be averaged to minimise variability to 5%.

METHODS

A single-centre, prospective, cross-sectional cohort study of uncomplicated singleton pregnancies at 20-37 week's gestation. From each patient 100 PWD waveforms were acquired including the umbilical artery (UA), middle cerebral artery (MCA) and uterine arteries (UtAs), with 30 waveforms acquired from the ductus venosus. Each waveform was individually measured using the machine's in-built software in automated mode. The variability was assessed using coefficient of variation. The number of waveforms to be averaged was calculated using the moving average and standard error of mean.

RESULTS

From a cohort of 200 pregnancies, a total of 189 were analysed. The pulsatility index (PI) demonstrated greater variability compared with the resistance index (RI) in all vessels studied. A minimum of 14 UA and MCA, and 13 UtA PWD waveforms were required to reduce PI variability to 5%, while only 2 RI waveforms were required for UA, 1 for MCA and 8 for UtAs.

CONCLUSION

The variability shown across all PWD indices and between vessels means that PWD indices results should be interpreted cautiously and averaged over multiple waveforms. Consideration should be given to adoption of RI, as it showed greater stability than PI for maternal-fetal Doppler.

Impact of suspected preterm labour in foetal cardiovascular and metabolic programming: a prospective cohort study protocol

INTRODUCTION

Suspected preterm labour (SPL) is an obstetric complication that occurs in 9% of all pregnancies and is the leading cause of antenatal hospital admissions. More than half of women with SPL deliver a premature baby which is a known risk factor for developing cardiovascular and metabolic disorders in childhood and later in adult life. On the other hand, the other half of these women will deliver at term, labelled as 'false preterm labour'. Although this has been thought to be a benign condition, accumulating evidence reported in recent years showed long-term effects for the foetus, neonate and infant even when birth occurs at term. However, the impact of SPL on cardiovascular and metabolic programming has not been studied yet. The aim of this prospective cohort study is to evaluate the impact of SPL on cardiac remodelling and function and on cardiovascular and metabolic profiles independently of gestational age at birth.

METHODS AND ANALYSIS

Prospective cohort study of subjects exposed and not exposed to an episode of SPL. Women with singleton pregnancies who are admitted at a tertiary hospital due to SPL and matched controls will be recruited. Evaluation of cardiovascular remodelling by foetal echocardiography will be performed during admission. Cord blood will be collected at birth in order to analyse different metabolomic footprints and several cardiovascular and metabolic risk biomarkers. Moreover, children will undergo an echocardiography 6 months after birth. The relationship between SPL and cardiovascular and metabolic programming will be modelled considering different covariates such as socioeconomic factors, perinatal characteristics, lifestyle, diet and exercise.

ETHICS AND DISSEMINATION

Ethical approval was granted in April 2020 from CEIC Aragón (CEICA) (C.P.-C.I. PI20/136). Study outcomes will be disseminated at international conferences and published in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05670665.

Added Value in Low-Risk Pregnancies of Longitudinal Changes in Uterine Doppler and Circulating Angiogenic Factors during the Third Trimester in Predicting Term Preeclampsia

INTRODUCTION

The objective of this study was to assess the relationship between longitudinal changes in the uterine Doppler velocimetry and the maternal profile of angiogenic factors in the third trimester and to assess their ability to predict term preeclampsia (PE).

METHODS

A cohort of low-risk pregnant women was scheduled for a uterine Doppler evaluation and measurement of the circulating levels of angiogenic factors at ∼30 and ∼36 weeks. The performance of both parameters and their change over time in predicting term PE was evaluated.

RESULTS

A total of 1,191 women were analyzed, of which 28 (2.4%) women developed term PE. At ∼30 weeks, a model including the sFlt-1/PlGF (fms-like tyrosine kinase-1/placental growth factor) ratio and the uterine Doppler explained 16.2% of the uncertainty of developing term PE, while at ∼36 weeks, the same variables explained 25.2% [p < 0.001]. The longitudinal changes of both predictors had an R2 of 26.8%, which was not different from that of the ∼36 weeks evaluation [p = 0.45]. The area under the curve (AUC) of the ∼36 weeks ratio was significantly higher than at ∼30 weeks (0.86 [0.77-0.94] vs. 0.81 [0.73-0.9]; p = 0.043). The AUC of the longitudinal change of the ratio (0.85 [0.77-0.94]) did not differ from that of at ∼36 weeks (p = 0.82). At ∼36 weeks, for a 10% of false positives, the ratio had a detection rate of 71.4%.

CONCLUSION

A cross-sectional measurement of the sFlt-1/PlGF ratio outperforms uterine Doppler in predicting term PE. The combination of both markers does not improve such prediction, nor the evaluation of the longitudinal changes between weeks.

Assessment of fetal cardiac function in pregnant women with anemia: prospective case-control study

OBJECTIVE

To compare fetal cardiac function in pregnant women with iron deficiency anemia (IDA) vs healthy pregnant controls.

METHODS

This was a single-center, prospective, case-control study conducted in a tertiary hospital between November 2022 and September 2023. Women diagnosed with IDA who attended as outpatients at the pregnancy follow-up clinic at 30-34 weeks' gestation or who were hospitalized for intravenous iron treatment owing to profound anemia were included. The control group consisted of randomly selected gestational-age-matched pregnant women with no obstetric complications or comorbidities and who did not have anemia. Patients underwent two-dimensional imaging, followed by pulsed-wave Doppler and M-mode and tissue Doppler imaging (TDI) to evaluate fetal cardiac function. A fetal cardiac score was calculated using systolic, diastolic and global hemodynamic function parameters, and was compared between patients with IDA and those without. The fetal cardiac score was also assessed according to the severity of anemia in the IDA group.

RESULTS

A total of 150 patients, comprising 50 patients with IDA and 100 healthy pregnant women at 30-34 weeks' gestation, were included in the study. Of the patients with IDA, 20 had mild, 18 had moderate and 12 had severe anemia. The fetal myocardial performance index and isovolumetric relaxation time were significantly higher in the IDA group compared with the control group (P < 0.0001 for both), while isovolumetric contraction time was similar. Among the fetal tricuspid and mitral valve diastolic parameters, the E, A and E/A values were significantly lower in the IDA group (P < 0.05 for all). Mitral (MAPSE) and tricuspid (TAPSE) annular plane systolic excursions were significantly lower in the IDA group (P < 0.05 for both). The IDA group also had significantly lower values for the TDI parameters mitral and tricuspid E', A', S' and E'/A' ratio and a significantly higher E/E' ratio (P < 0.05 for all). Among the IDA subgroups, a significant decrease was observed in the tricuspid and mitral A, E and E/A ratio in fetuses whose mothers had severe anemia (P = 0.001). M-mode Doppler analysis revealed significantly lower fetal TAPSE and MAPSE in the patient group with severe maternal anemia (P = 0.001 for both). According to the subgroup comparison of TDI findings, the fetuses of mothers with severe anemia had significantly lower tricuspid and mitral E', A', S' and E'/A' ratio values and a significantly higher E/E' ratio (P < 0.05 for all). The fetal cardiac score was significantly higher in the maternal IDA group compared with the control group (P < 0.001). A significant negative correlation was found between maternal hemoglobin level and fetal cardiac score (P < 0.001).

CONCLUSIONS

We observed differences in fetal systolic and diastolic cardiac function in pregnancies with maternal IDA. Fetal cardiac function was affected more among patients with severe anemia. This study found an increased E/E' ratio in the fetuses of pregnant women with IDA, suggesting decreased fetal heart maturation. Prenatal fetal cardiac evaluation, especially in women with severe anemia, can facilitate a more seamless transition to the postnatal period for these newborns. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Value of Cerebroplacental Ratio in Predicting Adverse Perinatal Outcome in Term Pregnancies Complicated by Obesity

Objectives

To evaluate the performance of cerebroplacental ratio (CPR) in predicting composite adverse perinatal outcome (CAPO) in women with obesity compared to non-obese women at term.

Methods

This is a retrospective cohort study in a single tertiary referral centre over a 3-year period. All singleton pregnancies with CPR measurements ≥ 37 + 0 weeks and estimated fetal weight ≥ 10 th centile and attempted vaginal delivery were included and divided into two groups defined by pre-pregnancy body mass index (BMI)

Results

The study cohort included 1207 pregnancies, of which 112 were women with a BMI ≥ 30 kg/m 2 . In obese women, CAPO occurred in 21 cases (18.8%) compared to 247 (22.6%) cases in women with BMI < 30 kg/m 2 (p = 0.404). In the entire study cohort, CPR MoM was significantly lower in the CAPO and OD for IFC group. ROC analyses revealed a significant predictive value of low CPR MoM for CAPO in obese women (AUC = 0.64, p = 0.024). Furthermore, CPR was predictive for OD for IFC not only in obese (AUC = 0.72, p = 0.023) but also in non-obese (AUC = 0.61, p = 0.003) women.

Conclusions

Low CPR MoM was predictive for CAPO and OD for IFC in obese women without additional risk factors. However, the overall predictive performance of CPR for CAPO in obese women was poor.

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Key Words

• BMI
• adverse perinatal outcome
• cerebroplacental ratio
• obesity

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Affiliation(s)

Gabriel Eisenkolb Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Anne Karge Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Javier U. Ortiz Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Eva Ostermayer Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Silvia M. Lobmaier Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Bettina Kuschel Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany
Oliver Graupner Department of Gynecology and Obstetrics, TUM School of Medicine and Health, Technical University Munich (TUM), TUM University Hospital, Munich, Germany

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AI-enabled workflow for automated classification and analysis of feto-placental Doppler images

Introduction

Extraction of Doppler-based measurements from feto-placental Doppler images is crucial in identifying vulnerable new-borns prenatally. However, this process is time-consuming, operator dependent, and prone to errors.

Methods

To address this, our study introduces an artificial intelligence (AI) enabled workflow for automating feto-placental Doppler measurements from four sites (i.e., Umbilical Artery (UA), Middle Cerebral Artery (MCA), Aortic Isthmus (AoI) and Left Ventricular Inflow and Outflow (LVIO)), involving classification and waveform delineation tasks. Derived from data from a low- and middle-income country, our approach's versatility was tested and validated using a dataset from a high-income country, showcasing its potential for standardized and accurate analysis across varied healthcare settings.

Results

The classification of Doppler views was approached through three distinct blocks: (i) a Doppler velocity amplitude-based model with an accuracy of 94%, (ii) two Convolutional Neural Networks (CNN) with accuracies of 89.2% and 67.3%, and (iii) Doppler view- and dataset-dependent confidence models to detect misclassifications with an accuracy higher than 85%. The extraction of Doppler indices utilized Doppler-view dependent CNNs coupled with post-processing techniques. Results yielded a mean absolute percentage error of 6.1 ± 4.9% (n = 682), 1.8 ± 1.5% (n = 1,480), 4.7 ± 4.0% (n = 717), 3.5 ± 3.1% (n = 1,318) for the magnitude location of the systolic peak in LVIO, UA, AoI and MCA views, respectively.

Conclusions

The developed models proved to be highly accurate in classifying Doppler views and extracting essential measurements from Doppler images. The integration of this AI-enabled workflow holds significant promise in reducing the manual workload and enhancing the efficiency of feto-placental Doppler image analysis, even for non-trained readers.

Does Insulin Treatment Affect Umbilical Artery Doppler Indices in Pregnancies Complicated by Gestational Diabetes?

Background/Objectives: Gestational diabetes mellitus (GDM) is one of the most common morbidities of pregnancy. The impact of increased maternal blood glucose on fetoplacental hemodynamics is not fully elucidated, especially in patients with uncontrolled GDM necessitating insulin therapy. The objective of this study was to assess the impact of insulin therapy on the umbilical artery dopplers in GDM pregnancies adequate for gestational-age fetuses. Methods: Retrospective observational study among 447 GDM pregnant women, divided according to their treatment (nutritional therapy (NT), long acting (LA) insulin, combined insulin) and 100 healthy controls with the same gestational age. The umbilical artery pulsatility index (UA-PI) was recorded at 28, 32 and 36 weeks. Results: UA-PI values declined in both GDM and healthy controls at all three time intervals. The combined insulin group showed reduced UA-PI values in comparison to the LA insulin group, but the difference never reached statistical significance. The combined insulin group exhibited significantly reduced UA-PI values at 32- and 36-weeks' gestation compared to the NT groups. Conclusions: A decreased impedance to blood flow in the umbilical artery of diabetic mothers on insulin therapy was observed. This was more pronounced during the last trimester. The extent to which umbilical artery PI can predict unfavorable outcomes has yet to be determined. Further additional studies are necessary to confirm the precise impact of glucose levels and medical interventions on the circulation of both the fetus and the mother.

Adverse perinatal outcomes are strongly associated with degree of abnormality in uterine artery Doppler pulsatility index

OBJECTIVE

To investigate the association between varying degrees of abnormality in the Doppler uterine artery pulsatility index (UtA-PI) and adverse perinatal outcome.

METHODS

This was a prospective study of women with a singleton, non-anomalous pregnancy in whom UtA-PI was measured universally in midpregnancy and who gave birth in Oxford University Hospitals, Oxford, UK, between 2016 and 2023. Relative risk ratios (RRR) for the primary outcomes of extended perinatal mortality and live birth with a severe small-for-gestational-age (SGA) neonate were calculated using multinomial logistic regression, for early preterm birth (before 34 + 0 weeks' gestation) and late preterm/term birth (at or after 34 + 0 weeks). Risks were also investigated for iatrogenic preterm birth and a composite adverse outcome before 34 + 0 weeks.

RESULTS

Overall, 33 364 pregnancies were included in the analysis. Compared to those with a normal UtA-PI, the risk of extended perinatal mortality with delivery before 34 + 0 weeks was higher in women with UtA-PI ≥ 90th percentile (RRR, 4.7 (95% CI, 2.7-8.0); P < 0.001), but this was not demonstrated in births at or after 34 + 0 weeks. The risk of live birth with severe SGA was associated strongly with abnormal UtA-PI for early births (RRR, 26.0 (95% CI, 11.6-58.2); P < 0.001) and later births (RRR, 2.3 (95% CI, 1.8-2.9); P < 0.001). Women with raised UtA-PI were more likely to have an early iatrogenic birth (RRR, 7.8 (95% CI, 5.5-11.2); P < 0.001). For each outcome before 34 + 0 weeks and the composite outcome, the risk increased significantly in association with the degree of abnormality in the UtA-PI (from < 90th, 90-94th, 95-98th to ≥ 99th percentile) (Ptrend < 0.001). When using the 90th percentile as opposed to the 95th, there was a significant improvement in the overall predictive accuracy (as determined by the area under the receiver-operating-characteristics curve) for the composite adverse outcome (χ2 = 6.64, P = 0.01) and iatrogenic preterm birth (χ2 = 4.10, P = 0.04).

CONCLUSIONS

Elevated UtA-PI is a key predictor of iatrogenic preterm birth, severe SGA and perinatal loss up to 34 + 0 weeks' gestation. The 90th percentile for UtA-PI should be used, and management should be tailored according to the degree of abnormality, as pregnancies with very raised UtA-PI measurement constitute a group at extreme risk of adverse outcome. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Amniotic-umbilical-to-cerebral ratio, a Doppler index for estimating adverse perinatal outcomes in fetal growth restriction

OBJECTIVE

To evaluate amniotic fluid volume with Doppler parameters and its association with composite adverse perinatal outcomes (CAPOs) in fetal growth restriction (FGR).

MATERIALS AND METHODS

This study was conducted prospectively in a tertiary referral center between 2023 and 2024 on pregnant women diagnosed with early- and late-onset FGR. Fetal ultrasonographic measurements, including deepest vertical pocket (DVP) for amniotic fluid, and Doppler parameters including uterine artery (UtA) systolic/diastolic (S/D) and pulsatility index (PI), middle cerebral artery (MCA) S/D and PI, and umbilical artery (UA) S/D and PI, were conducted following fetal biometry. The cerebroplacental ratio (CPR), cerebral ratio, cerebro-placental-uterine ratio (CPUR), and amniotic-umbilical-to-cerebral ratio (AUCR) were all calculated. Pregnant women diagnosed with FGR were planned to give birth after 37 weeks' gestation, unless a pregnancy complication requiring earlier delivery occurred. We assessed perinatal outcomes subsequent to delivery, with CAPOs defined as the presence of at least one adverse outcome: 5th minute APGAR score <7, respiratory distress syndrome (RDS), umbilical cord blood pH <7.2, and neonatal intensive care unit (NICU) admission.

RESULTS

The study included 132 participants, divided into early- (n = 32) and late-onset FGR (n = 100) groups. AUCR was significantly lower in fetuses with late-onset FGR who experienced CAPOs. Multivariate analysis showed gestational age at birth and birth weight were significant predictors of CAPOs in early-onset FGR, while gestational age, birth weight, and AUCR were significant predictors in late-onset FGR. CPR, UCR, and CPUR did not show significance in predicting CAPOs in both early- and late-onset FGR on multivariate analysis.

CONCLUSIONS

AUCR is a potential reliable marker for predicting adverse perinatal outcomes in late-onset FGR.

First-trimester Doppler Ultrasound for Predicting Successful Management of Pregnancy with Recurrent Pregnancy Losses Due to Antiphospholipid Syndrome and Thrombophilia: A Cohort Study

Background

Recurrent pregnancy loss (RPL) often stems from a hypercoagulable state that exacerbates conditions such as antiphospholipid syndrome (APS) and thrombophilia, leading to early placental issues. Although treatments such as low-molecular-weight heparin (LMWH) and low-dose aspirin (LDA) are used, outcomes vary. This study proposes using first-trimester Doppler ultrasound - specifically, uterine radial artery resistance index (URa-RI) at 8 weeks and uterine artery pulsatility index (Ut-PI) with pre-diastolic notching (Ut-notch) at 11-13 weeks - to better predict successful pregnancies and reduce risks of adverse outcomes.

Aim

The aim of this study was to evaluate URa-RI, Ut-PI and Ut-notch between successful pregnancy and not successful and between pregnancy with adverse events and without.

Settings and Design

The study was conducted in a clinical setting, using a retrospective cohort design on a sample of 72 patients with a history of two or more RPL episodes.

Materials and Methods

Data on URa-RI measured at 8 weeks and Ut-PI and Ut-notch measured at 11-13 weeks were collected. Maternal characteristics - including age, BMI, number of pregnancy losses, etiopathology and immuno-inflammatory response - were considered in the analysis.

Statistical Analysis Used

Comparative statistical analysis was performed on URa-RI, Ut-PI and Ut-notch data, evaluating their associations with pregnancy success and adverse outcomes. Variables were statistically compared between successful and unsuccessful pregnancies and also analysed for adverse events. Analysis was performed using SPSS (IBM, 27th edition). Chi-square tests were applied to nominal categories and multivariate logistic regression adjusted for age, body mass index (BMI), previous pregnancy losses, etiopathology and antinuclear antibody positivity. Primary outcomes (URa-RI, Ut-PI and Ut-notch) were reported with odds ratios and 95% confidence intervals (CIs).

Results

Low URa-RI (<0.45) at 8 weeks gives a 16.4 times higher chance for the management to be successful and result in a healthy take-home baby (95% CI = 4.4-61, P < 0.0001). The mean URa-RI was also significantly higher in unsuccessful pregnancy (0.50 ± 0.09 vs. 0.38 ± 0.04, P < 0.0001). High Ut-PI and positive Ut-notch result in a significant increase of adverse event risk, which are 19.4 times and 8.1 times, respectively (95% CI = 4.2-51.6 and 3.12-20.5, P < 0.0001).

Conclusion

This study demonstrates the utility of first-trimester Doppler ultrasound (URa-RI, Ut-PI and Ut-notch) in predicting pregnancy success and adverse events in patients with RPL, particularly those managed with LMWH and LDA. These ultrasound markers may provide valuable guidance in managing and anticipating outcomes in RPL cases related to thrombophilia and APS.

Assessment of the fetal thymic-thoracic ratio in pregnant women with intrahepatic cholestasis: a prospective case-control study

OBJECTIVES

To examine the fetal thymic-thoracic ratio (TTR) in intrahepatic cholestasis of pregnancy (ICP).

METHODS

This prospective case-control study was conducted in a single tertiary center. The sample consisted of 86 pregnant women at 28-37 weeks of gestation, including 43 women with ICP and 43 healthy controls. TTR was calculated for each patient using the anterior-posterior measurements of the thymus and intrathoracic mediastinal measurements.

RESULTS

The median TTR value was found to be smaller in the ICP group compared to the control group (0.32 vs. 0.36, p<0.001). The ICP group had a greater rate of admission to the neonatal intensive care unit (NICU) (p<0.001). Univariate regression analysis revealed that lower TTR values increased the possibility of NICU admission six times (95 % confidence interval: 0.26-0.39, p=0.01). A statistically significant negative correlation was detected between TTR and the NICU requirement (r: -0.435, p=0.004). As a result of the receiver operating characteristic analysis, in predicting NICU admission, the optimal cut-off value of TTR was determined to be 0.31 with 78 % sensitivity and 67 % specificity (area under the curve=0.819; p<0.001).

CONCLUSIONS

We determined that the fetal TTR may be affected by the inflammatory process caused by the maternal-fetal immune system and increased serum bile acid levels in fetal organs in the presence of ICP. We consider that TTR can be used to predict adverse pregnancy outcomes in patients with ICP.

The sFlt-1/PlGF-ratio and the risk of preeclampsia-related adverse outcomes in subsequent pregnancies with signs and symptoms of a preeclampsia

OBJECTIVES

This study characterizes the outcome of two subsequent pregnancies with suspected preeclampsia (PE). We investigated the diagnostic accuracy of clinical signs, Doppler examinations, and the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF)-ratio to predict PE-related adverse outcomes (AO). The sFlt-1/PlGF-ratio of the first pregnancy was compared to the outcome of the subsequent pregnancy.

STUDY DESIGN

A total of 1928 patients at risk for preeclampsia were screened, of them 1117 were eligible for inclusion. Of these, 84 women presented with suspected PE in two subsequent pregnancies.

OUTCOME MEASURES

Diagnostic accuracy of clinical markers was assessed. Associations between the sFlt-1/PlGF-ratio in the first and the odds of an AO in the subsequent pregnancy were investigated with logistic regression.

RESULTS

The prevalence of AOs decreased from 27.4 % in the first to 17.9 % in the second pregnancy. Comparison of the accuracy of the different clinical markers for an AO showed a high specificity for an sFlt-1/PlGF-ratio at the cut-off of ≥ 85 in both pregnancies (81.3 %, 95 % CI 63.6-92.8 vs 92.6 %,95 % CI 83.7-97.6), but a lower sensitivity in the second pregnancy (92.9 %, 95 % CI 66.1-99.8 vs 33.3%, 95 % CI 11.8-61.6). An elevated sFlt-1/PlGF-ratio in the first did not increase the odds of an AO in the subsequent pregnancy.

CONCLUSIONS

The prevalence of AOs decreases in subsequent pregnancies. Our finding that the sFlt-1/PlGF-ratio of the first was not related to the outcome of the subsequent pregnancy suggests that angiogenic markers are only a within-pregnancy short-term tool to assess AOs.

The role of the cerebro-placental-uterine ratio in predicting composite adverse perinatal outcomes in patients with pregnancy-induced hypertension

OBJECTIVES

To examine the role of the cerebro-placental-uterine ratio (CPUR) in predicting composite adverse perinatal outcomes (CAPO) in patients with pregnancy-induced hypertension (PIH).

STUDY DESIGN

This prospective, case-control study was conducted at a tertiary hospital with 110 cases of PIH, including 70 patients with preeclampsia and 40 with gestational hypertension, and 110 healthy controls. The middle cerebral artery pulsatility index (MCA-PI), umbilical artery pulsatility index (UA-PI), and uterine artery pulsatility index (UtA-PI) were measured, and the cerebro-placental ratio (CPR=MCA-PI/UA-PI) and CPUR (CPR/UtA-PI) were calculated.

MAIN OUTCOME MEASURE

The role of CPUR in predicting CAPO in preeclampsia and gestational hypertension.

RESULTS

The CPR and CPUR values were lower in the PIH group compared to the control group (p < 0.001). CAPO had a negative correlation with CPR and CPUR (p < 0.001). Univariate regression analysis revealed that the likelihood of CAPO was increased four times by a low CPR value and six times by a low CPUR value. In the ROC analysis, the optimal cut-off value of CPR in predicting CAPO was 1.33 with 74 % sensitivity and 66 % specificity (area under the curve [AUC] = 0.778; p < 0.001) in PIH. For CPUR, the optimal cut-off value was 1.32, at which 82 % sensitivity and 79 % specificity in predicting CAPO (AUC=0.826; p < 0.001).

CONCLUSION

CPUR was determined to be successful with high sensitivity in predicting adverse perinatal outcomes in the presence of PIH. In addition, CPUR was more effective in predicting CAPO in patients with preeclampsia compared to gestational hypertension. CPUR can be used to predict adverse outcomes in patients with PIH.

Impact of a Stage-Based Classification on the Incidence of Fetal Growth Restriction, Preterm Birth Rates, and Birthweight in a Rural Community of Central India

INTRODUCTION

The objective of this study was to determine the impact of the stage-based classification of fetal growth restriction (FGR) on the magnitude of FGR, preterm births (PTBs), and birthweight (BW) in a rural population of Madhya Pradesh in Central India.

METHODS

The program covered 168 public sector centers for pregnant women and infants that provided services to nearly 220,000 people. The third-trimester assessments included fetal biometry, growth and environment assessments, and Doppler assessments. Fetal growth was staged using the Barcelona protocol as stages 1-4 FGR, small for gestational age, and no FGR. The data from the last ultrasound assessment before childbirth were considered. Regular training programs covering preconception care, antenatal and postnatal care were organized in the local language for the public sector community health workers of the program district. Childbirth outcomes were collected from the obstetric service of the local public sector hospital.

RESULTS

The analysis included 1,229 pregnancies from 2019 to 2023. The overall magnitude of FGR using estimated fetal weight <10th centile was 19.61% and reduced to 13.34% with the stage-based classification. The magnitude of FGR using the stage-based classification reduced from 27.59% in 2019 to 8.95% in 2023. The PTB in the stage-based FGR subgroup declined from 35.0% in 2019 to 3.45% in 2023 and 96.55% of the stage 1 FGR babies in 2023 were delivered at term. The overall mean BW in the program area improved from 2,772.41 (357.11) g in 2019 to 2,819.68 (377.31) g in 2023. The perinatal mortality rate (8.95 per 1,000 pregnancies) in the program area for 2019-2023 was much lower than the 31.9 per 1,000 pregnancies reported for Madhya Pradesh.

CONCLUSION

The change to a stage-based classification of FGR integrated with low-dose aspirin and fetal Doppler studies reduced the incidence of FGR and PTB and perinatal mortality and increased BW in this rural community.

Static and dynamic responses to hyperoxia of normal placenta across gestation with T2*-weighted MRI sequences

OBJECTIVES

T2*-weighted magnetic resonance imaging (MRI) sequences have been identified as non-invasive tools with which to study placental oxygenation in vivo. This study aimed to use these to investigate both static and dynamic responses to hyperoxia of the normal placenta across gestation.

METHODS

We conducted a single-center prospective study including 52 uncomplicated pregnancies. Two T2*-weighted sequences (T2* relaxometry) were performed, one before and one after maternal hyperoxia. The distribution of placental T2* values was modeled by fitting a gamma probability density function (T2* ~ Γ α β ), describing the structure of the histogram using the mean T2* value, the shape parameter (α) and the rate (β). A dynamic acquisition (blood-oxygen-level-dependent (BOLD) MRI) was also performed before and during maternal oxygen supply, until placental oxygen saturation had been achieved. The signal change over time was modeled using a sigmoid function, to determine the intensity of enhancement (ΔBOLD (% with respect to baseline)), a temporal variation coefficient (λ (min-1), controlling the slope of the curve) and the maximum steepness (Vmax (% of placental enhancement/min)).

RESULTS

The histogram analysis of the T2* values in normoxia showed a whole-placenta variation, with a decreasing linear trend in the mean T2* value (Pearson's correlation coefficient (R) = -0.83 (95% CI, -0.9 to -0.71), P < 0.001), along with an increasingly peaked and narrower distribution of T2* values with advancing gestation. After maternal hyperoxia, the mean T2* ratios (mean T2*hyperoxia/mean T2*baseline) were positively correlated with gestational age, while the other histogram parameters remained stable, suggesting a translation of the histogram towards higher values with a similar appearance after maternal hyperoxia. ΔBOLD showed a non-linear increase across gestation. Conversely, λ showed an inverted trend across gestation, with a weaker correlation (R = -0.33 (95% CI, -0.58 to -0.02), P = 0.04, R2 = 0.1). As a combination of ΔBOLD and λ, the changes in Vmax throughout gestation were influenced mainly by the changes in ΔBOLD and showed a positive non-linear correlation with gestational age.

CONCLUSIONS

Our results suggest that the decrease in the T2* placental signal as gestation progresses does not reflect placental dysfunction. The BOLD dynamic signal change is representative of a free-diffusion model of oxygenation and highlights the increasing differences in oxygen saturation between mother and fetus as gestation progresses (ΔBOLD) and in the placental permeability to oxygen (λ). © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Influence of Cesarean Section Scar on the Mean Pulsatility Index of the Uterine Artery Doppler between 20 and 34 Weeks of Gestation

Objective

The aim of this study was to assess the influence of the cesarean section scars on the mean pulsatility index (PI) of the uterine artery Doppler between 20 and 34 weeks of gestation. A secondary objective was to assess the association between previous cesarean section and adverse maternal/perinatal outcomes.

Methods

A retrospective cohort study was conducted with pregnant women who had their deliveries between March 2014 and February 2023. PI of the uterine arteries Doppler was performed transvaginally between 20-24 weeks and transabdominally between 28-34 weeks. The following variables were considered adverse perinatal outcomes: birth weight < 10th percentile for gestational age, preeclampsia, premature birth, placental abruption, perinatal death, postpartum hemorrhage, neonatal intensive care unit (NICU) admission.

Results

A total of 479 pregnant women were included in the final statistical analysis, being that 70.6% (338/479) had no (Group I) and 29.4% (141/479) had at least one previous cesarean section (Group II). Pregnant women with a previous cesarean had higher median of mean PI (1.06 vs. 0.97, p = 0.044) and median MoM of mean PI uterine arteries Doppler (1.06 vs. 0.98, p = 0.037) than pregnant women without previous cesarean section at ultrasound 20-24 weeks. Pregnant women with a previous cesarean section had higher median of mean PI (0.77 vs. 0.70, p < 0.001) and mean MoM PI uterine arteries Doppler (1.08 vs. 0.99, p < 0.001) than pregnant women without previous cesarean section at ultrasound 28-34 weeks. Pregnant women with ≥ 2 previous cesarean sections had a higher median of mean PI uterine arteries Doppler than those with no previous cesarean sections (1.19 vs. 0.97, p = 0.036). Group II had a lower risk of postpartum hemorrhage (aPR 0.31, 95% CI 0.13-0.75, p = 0.009) and composite neonatal outcome (aPR 0.66, 95% CI 0.49-0.88, p = 0.006). Group II had a higher risk of APGAR score at the 5th minute < 7 (aPR 0.75, 95% CI 1.49-51.29, p = 0.016).

Conclusion

The number of previous cesarean sections had a significant influence on the mean PI uterine arteries Doppler between 20-24 and 28-34 weeks of gestation. Previous cesarean section was an independent predictor of postpartum hemorrhage and APGAR score at the 5th minute < 7. Pregnancy-associated arterial hypertension and number of previous deliveries influenced the risk of composite neonatal outcome, but not the presence of previous cesarean section alone.

Fetal MRI-Based Body and Adiposity Quantification for Small for Gestational Age Perinatal Risk Stratification

BACKGROUND

Small for gestational age (SGA) fetuses are at risk for perinatal adverse outcomes. Fetal body composition reflects the fetal nutrition status and hold promise as potential prognostic indicator. MRI quantification of fetal anthropometrics may enhance SGA risk stratification.

HYPOTHESIS

Smaller, leaner fetuses are malnourished and will experience unfavorable outcomes.

STUDY TYPE

Prospective.

POPULATION

40 SGA fetuses, 26 (61.9%) females: 10/40 (25%) had obstetric interventions due to non-reassuring fetal status (NRFS), and 17/40 (42.5%) experienced adverse neonatal events (CANO). Participants underwent MRI between gestational ages 30 + 2 and 37 + 2.

FIELD STRENGTH/SEQUENCE

3-T, True Fast Imaging with Steady State Free Precession (TruFISP) and T1-weighted two-point Dixon (T1W Dixon) sequences.

ASSESSMENT

Total body volume (TBV), fat signal fraction (FSF), and the fat-to-body volumes ratio (FBVR) were extracted from TruFISP and T1W Dixon images, and computed from automatic fetal body and subcutaneous fat segmentations by deep learning. Subjects were followed until hospital discharge, and obstetric interventions and neonatal adverse events were recorded.

STATISTICAL TESTS

Univariate and multivariate logistic regressions for the association between TBV, FBVR, and FSF and interventions for NRFS and CANO. Fisher's exact test was used to measure the association between sonographic FGR criteria and perinatal outcomes. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. A P-value <0.05 was considered statistically significant.

RESULTS

FBVR (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.2-0.76) and FSF (OR 0.95, CI 0.91-0.99) were linked with NRFS interventions. Furthermore, TBV (OR 0.69, CI 0.56-0.86) and FSF (OR 0.96, CI 0.93-0.99) were linked to CANO. The FBVR sensitivity/specificity for obstetric interventions was 85.7%/87.5%, and the TBV sensitivity/specificity for CANO was 82.35%/86.4%. The sonographic criteria sensitivity/specificity for obstetric interventions was 100%/33.3% and insignificant for CANO (P = 0.145).

DATA CONCLUSION

Reduced TBV and FBVR may be associated with higher rates of obstetric interventions for NRFS and CANO.

EVIDENCE LEVEL

2 TECHNICAL EFFICACY: Stage 5.

Fetal hemodynamics and placental histopathology in Down syndrome

OBJECTIVE

To evaluate the association between Doppler patterns in fetuses with Down syndrome (DS) and their placental histopathologic findings.

METHODS

A retrospective cross-sectional study was performed by collecting data from medical records of singleton pregnancies between January 2014 and January 2022, whose fetuses had a confirmed diagnosis of DS either prenatally or postnatally. Placental histopathology, maternal characteristics, and prenatal ultrasound (biometric parameters and umbilical artery [UA] Doppler) were evaluated.

RESULTS

Of 69 eligible pregnant women, 61 met the inclusion and exclusion criteria. In the sample, 15 fetuses had an estimated fetal weight < 10th percentile for gestational age (GA) and were considered small for gestational age (SGA). Thirty-eight fetuses had increased resistance on the UA Doppler. Histologic changes were detected in 100% of the placentas, the most common being delayed villous maturation, alterations associated with poor fetal vascular perfusion, and villous dysmorphism. More than 50% of the placentas showed alterations related to placental insufficiency. We did not observe a statistically significant association between UA Doppler examination and placental alterations. All placentas analyzed in the SGA subgroup showed findings compatible with placental insufficiency.

CONCLUSION

We found no statistically significant association between placental histopathologic findings and UA Doppler abnormalities in fetuses with DS. The placental alterations identified were delayed villous maturation, alterations associated with poor fetal vascular perfusion, and villous dysmorphism.

The association between discordant umbilical arterial resistance in growth-restricted fetuses and adverse outcomes

BACKGROUND

Assessing the umbilical artery pulsatility index via Doppler measurements plays a crucial role in evaluating fetal growth impairment.

OBJECTIVE

This study aimed to investigate perinatal outcomes associated with discordant pulsatility indices of umbilical arteries in fetuses with growth restriction.

STUDY DESIGN

In this retrospective cohort study, all singleton pregnancies were included if their estimated fetal weight and/or abdominal circumference fell below the 10th percentile for gestational age (2017-2022). Eligible cases included singleton pregnancies with concurrent sampling of both umbilical arteries within 14 days of birth at the ultrasound evaluation closest to delivery. The exclusion criteria included births before 22 weeks of gestation, evidence of absent or reverse end-diastolic flow in either umbilical artery, and known fetal genetic or structural anomalies. The study compared cases with discordant umbilical artery pulsatility index values (defined as 1 umbilical artery pulsatility index at ≤95th percentile and the other umbilical artery pulsatility index at >95th percentile for gestational age) to pregnancies where both umbilical artery pulsatility indices had normal pulsatility index values and those with both umbilical arteries displaying abnormal pulsatility index values. The primary outcome assessed was the occurrence of composite adverse neonatal outcomes. Multivariable logistic regressions were performed, adjusting for relevant covariates.

RESULTS

The study encompassed 1014 patients, including 194 patients (19.1%) with discordant umbilical artery pulsatility index values among those who had both umbilical arteries sampled close to delivery, 671 patients (66.2%) with both umbilical arteries having normal pulsatility index values, and 149 patients (14.7%) with both umbilical arteries exhibiting abnormal values. Pregnancies with discordant umbilical artery pulsatility index values displayed compromised sonographic parameters compared with those with both umbilical arteries showing normal pulsatility index values. Similarly, the number of abnormal umbilical artery pulsatility index values was associated with adverse perinatal outcomes in a dose-response manner. Cases with 1 abnormal (discordant) umbilical artery pulsatility index value showed favorable sonographic parameters and perinatal outcomes compared with cases with both abnormal umbilical artery pulsatility index values, and cases with both abnormal umbilical artery pulsatility index values showed worse sonographic parameters and perinatal outcomes compared with cases with discordant UA PI values. Multivariate analysis revealed that discordant umbilical artery pulsatility indices were significantly and independently associated with composite adverse perinatal outcomes, with an adjusted odds ratio of 1.75 (95% confidence interval, 1.24-2.47; P = .002).

CONCLUSION

Evaluating the resistance indices of both umbilical arteries may provide useful data and assist in assessing adverse perinatal outcomes among fetuses with growth restriction.

Umbilical artery half peak systolic velocity deceleration time: a novel Doppler parameter for prediction of neonatal outcomes in pregnant women with preeclampsia

PURPOSE

To assess the effectiveness of half peak systolic velocity deceleration time (hPSV-DT) in predicting neonatal outcomes in pregnant women with preeclampsia and to compare its usefulness with the conventional umbilical artery (UA) pulsatility index (PI) approach.

METHODS

A prospective cohort study was conducted among pregnant women with preeclampsia who were admitted to the Department of Perinatology, Ministry of Health Ankara City Hospital between 01 September 2022 and 01 January 2023 at 28-41 weeks gestational age. 55 patients were divided into two groups: the study group with UA hPSV-DT value < 5th percentile (n = 22) and the control group with UA hPSV-DT value ≥ 5th percentile (n = 33). UA hPSV-DT calculates the time in milliseconds needed to halve the maximal velocity of the UA waveform using Doppler ultrasonography.

RESULTS

Birth weight, gestational age at birth, 1st minute APGAR, 5th minute APGAR, and umbilical cord pH values were significantly lower in the anormal hPSV-DT group (p < 0.05). Additionally, the rates of admission to NICU, respiratory distress syndrome (RDS), delivery time < 34 weeks, and birth weight < 2500 g were significantly more frequent in the anormal hPSV-DT group compared to the normal hPSV-DT group (p < 0.05). UA-PI > 95th percentile was detected in only 2 (8%) of 23 patients whose newborns were admitted to the NICU (p = 0.149), while hPSV-DT < 5th percentile was detected in 16 (69%) of 23 patients (p < 0.001). According to ROC analysis, the area under the curve was 0.82 (95% CI 0.06-0.28) for admission to the NICU. The best balance of sensitivity/specificity in ROC curves was 221.5 (82.6% sensitivity, 69.1% specificity, p < 0.001).

CONCLUSION

UA hPSV-DT was successful in predicting composite adverse perinatal outcomes in pregnant women with preeclampsia. It is a promising novel method that is accurate, quantitative, reproducible, and easily applicable. With further studies, this method may be a primary diagnostic tool in the management of high-risk pregnancies and in determining the optimal timing of delivery.

Utility of the cerebro-placental-uterine ratio in predicting composite adverse perinatal outcomes in pregestational diabetes: A prospective cohort study

PURPOSE

To examine the cerebro-placental-uterine ratio (CPUR) in pregnant women with pregestational diabetes and determine its role in predicting adverse prenatal outcomes.

METHODS

This prospective, cohort study conducted at a tertiary hospital included 65 patients with pregestational diabetes (25 with type1 diabetes, 40 with type2 diabetes) and 130 low-risk patients in the control group. The cerebroplacental (CPR) ratio and the CPUR were calculated. Composite adverse perinatal outcome (CAPO) is defined as the presence of any of the following: (1) Neonatal intensive care unit (NICU) admission, (2) Apgar at 5 min <7, and (3) umbilical cord arterial pH <7.10. The relationship of CPR and CPUR with CAPO was investigated.

RESULTS

CPR and CPUR were significantly lower in the pregestational diabetes group than in the control group. The NICU admission was higher in the case group. In receiver operating characteristic analyses, the optimal cut-off value of CPUR was 1.46 (AUC = 0.72, p = 0.003, 80% sensitivity, and 69% specificity) to predict CAPO and the optimal cut-off value of CPUR was 1.50 for NICU admission (AUC = 0.70, p = 0.013, 77% sensitivity, and 66% specificity).

CONCLUSION

Low CPUR values were found to be associated with adverse perinatal outcomes in women with pregestational diabetes. With the increasing number of studies, CPUR is expected to be utilized more widely in routine obstetric practice.

Prediction of Cesarean Section for Intrapartum Fetal Compromise: A Multivariable Model from a Prospective Observational Approach

OBJECTIVE

A cesarean section for intrapartum fetal compromise (IFC) is performed to avoid potential damage to the newborn. It is, therefore, crucial to develop an accurate prediction model that can anticipate, prior to labor, which fetus may be at risk of presenting this condition.

MATERIAL AND METHODS

To calculate a prediction model for IFC, the clinical, epidemiological, and ultrasonographic variables of 538 patients admitted to the maternity of La Fe Hospital were studied and evaluated using univariable and multivariable logistic regression analysis, using the area under the curve (AUC) and the Akaike Information Criteria (AIC).

RESULTS

In the univariable analysis, CPR MoM was the best single parameter for the prediction of CS for IFC (OR 0.043, p < 0.0001; AUC 0.72, p < 0.0001). Concerning the multivariable analysis, for the general population, the best prediction model (lower AIC) included the CPR multiples of the median (MoM), the maternal age, height, and parity, the smoking habits, and the type of labor onset (spontaneous or induction) (AUC 0.80, p < 0.0001). In contrast, for the pregnancies undergoing labor induction, the best prediction model included the CPR MoM, the maternal height and parity, and the smoking habits (AUC 0.80, p < 0.0001). None of the models included estimated fetal weight (EFW).

CONCLUSIONS

CS for IFC can be moderately predicted prior to labor using maternal characteristics and CPR MoM. A validation study is pending to apply these models in daily clinical practice.

Reduced gyrification in fetal growth restriction with prenatal magnetic resonance images

Placental-related fetal growth restriction, resulting from placental dysfunction, impacts 3-5% of pregnancies and is linked to elevated risk of adverse neurodevelopmental outcomes. In response, the fetus employs a mechanism known as brain-sparing, redirecting blood flow to the cerebral circuit, for adequate supply to the brain. In this study we aimed to quantitatively evaluate disparities in gyrification and brain volumes among fetal growth restriction, small for gestational age and appropriate-for gestational-age fetuses. Additionally, we compared fetal growth restriction fetuses with and without brain-sparing. The study encompassed 106 fetuses: 35 fetal growth restriction (14 with and 21 without brain-sparing), 8 small for gestational age, and 63 appropriate for gestational age. Gyrification, supratentorial, and infratentorial brain volumes were automatically computed from T2-weighted magnetic resonance images, following semi-automatic brain segmentation. Fetal growth restriction fetuses exhibited significantly reduced gyrification and brain volumes compared to appropriate for gestational age (P < 0.001). Small for gestational age fetuses displayed significantly reduced gyrification (P = 0.038) and smaller supratentorial volume (P < 0.001) compared to appropriate for gestational age. Moreover, fetal growth restriction fetuses with BS demonstrated reduced gyrification compared to those without BS (P = 0.04), with no significant differences observed in brain volumes. These findings demonstrate that brain development is affected in fetuses with fetal growth restriction, more severely than in small for gestational age, and support the concept that vasodilatation of the fetal middle cerebral artery reflects more severe hypoxemia, affecting brain development.

The role of second trimester uterine artery Doppler in predicting obstetric and neonatal outcomes in abnormal first trimester maternal serum pregnancy-associated plasma protein-A and free β-human chorionic gonadotropin values

AIM

This study aims to determine whether second-trimester uterine artery (UtA) Doppler combined with first-trimester abnormal pregnancy-associated plasma protein-A (PAPP-A) and β-human chorionic gonadotropin (β-Hcg) levels predicts adverse obstetric and neonatal outcomes.

MATERIALS AND METHODS

This study of 289 pregnant women included 196 with normal PAPP-A and free β-HCG values (control group) and 93 with abnormal values (study group) in the first-trimester screening test. Second-trimester UtA Doppler sonography was done in these pregnancies. The perinatal prediction and screening potential of UtA Doppler pulsatility index (PI) parameters were examined in the study group.

RESULTS

UtA PI >95 percentile increased birth before the 37th week by 4.46 times, birth before the 34th week by 7.44 times, preeclampsia risk by 3.25 times, fetal growth restriction (FGR) risk by 4.89 times, and neonatal intensive care unit (NICU) admission rates by 3.66 times in the study group (p < 0.05 for all). UtA PI >95 percentile had 49.2% sensitivity and 82.1% specificity for birth before 37 weeks. For birth before 34 weeks, sensitivity was 80.0% and specificity 65.0%. FGR has 70.5% sensitivity and 67.1% specificity. Screening for preeclampsia has 66.6% sensitivity and 61.9% specificity.

CONCLUSION

Adding UtA Doppler in the second trimester to pregnancies with abnormal PAPP-A and/or free β-Hcg values in the first trimester may be a useful screening method for adverse outcomes.

A longitudinal and cross-sectional study of placental circulation between normal and placental insufficiency pregnancies

INTRODUCTION

To longitudinally and cross-sectionally study the differences in the uterine artery pulsatility index (UTPI), umbilical artery pulsatility index (UAPI) and placental vascularization indices (PVIs, derived from 3-dimensional power Doppler) between normal and placental insufficiency pregnancies throughout gestation.

METHODS

UTPI, UAPI and PVI were measured 6 times at 4- to 5- week intervals from 11 to 13+6 weeks-36 weeks. Preeclampsia (PE) and fetal growth restriction (FGR) were defined as placental insufficiency. Comparisons of UTPI, UAPI and PVI between normal and insufficiency groups were performed by one-way repeated measures analysis of variance.

RESULTS

A total of 125 women were included: monitored regularly from the first trimester to 36 weeks of gestation: 109 with normal pregnancies and 16 with placental insufficiency. Longitudinal study of the normal pregnancy group showed that UTPI and UAPI decreased significantly every 4 weeks, while PVIs increased significantly every 8 weeks until term. In the placental insufficiency group however, this decrease occurred slower at 8 weeks intervals and UTPI stabilized after 24 weeks. No significant difference was noted in PVIs throughout pregnancy. Cross-sectional study from different stages of gestation showed that UTPI was higher in the insufficiency group from 15 weeks onward and PVIs were lower after 32 weeks.

DISCUSSION

Compared to high-risk pregnancies with normal outcome, UTPI and UAPI needed a longer time to reach a significant change in those with clinical confirmation of placental insufficiency pregnancies and no significant change was found in PVI throughout gestation. UTPI was the earliest factor in detecting adverse outcome pregnancies.