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Watthanasathitnukun W, Suwanrath C, Chainarong N, Petpichetchian C, Leelarujijareon C. Prevalence and Doppler Indices of Late-Onset Fetal Growth Restriction at a Single University Hospital in Southern Thailand. JOURNAL OF CLINICAL ULTRASOUND : JCU 2025; 53:753-760. [PMID: 39966094 DOI: 10.1002/jcu.23948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Revised: 12/13/2024] [Accepted: 12/16/2024] [Indexed: 02/20/2025]
Abstract
OBJECTIVES To evaluate the prevalence of late-onset fetal growth restriction (FGR), and comprehensively assess maternal and fetal Doppler indices by comparing the Doppler measurements of the uterine artery (UtA), umbilical artery (UA), umbilical vein (UV), middle cerebral artery (MCA), and ductus venosus (DV) between normal and FGR groups. METHODS This prospective study enrolled 306 singleton pregnant women at ≥ 32 weeks' gestation between June 1, 2023 and April 30, 2024. Fetal biometry and Doppler indices were measured via transabdominal ultrasonography by a single operator. The Mann-Whitney U test was used for statistical comparison. RESULTS Late-onset FGR prevalence was 4.9% (15/306). The FGR group had a significantly higher UtA pulsatility index (PI) and lower cerebroplacental ratio (CPR), cerebral-placental-uterine ratio (CPUR), and UV blood flow normalized for fetal abdominal circumference (UVBF/AC) compared to the normal group. CONCLUSION Late-onset FGR prevalence was approximately 5%. The higher UtA-PI and lower CPR, CPUR, and UVBF/AC in the FGR group indicated mild placental insufficiency.
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Affiliation(s)
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Natthicha Chainarong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Chusana Petpichetchian
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Chutinun Leelarujijareon
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
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Zhao Y, Xu L, An P, Zhou J, Zhu J, Liu S, Zhou Q, Li X, Xiong Y. A nomogram for predicting adverse perinatal outcome with fetal growth restriction: a prospective observational study. BMC Pregnancy Childbirth 2025; 25:132. [PMID: 39934709 PMCID: PMC11812188 DOI: 10.1186/s12884-025-07252-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Accepted: 01/28/2025] [Indexed: 02/13/2025] Open
Abstract
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.
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Affiliation(s)
- Ying Zhao
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Lei Xu
- Chang Ning Maternity & Infant Health Hospital, Shanghai, China
| | - Ping An
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jizi Zhou
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Jie Zhu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Shuangping Liu
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Qiongjie Zhou
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaotian Li
- Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, China.
| | - Yu Xiong
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.
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Ghi T, Fieni S, Ramirez Zegarra R, Pereira S, Dall'Asta A, Chandraharan E. Relative uteroplacental insufficiency of labor. Acta Obstet Gynecol Scand 2024; 103:1910-1918. [PMID: 39107951 PMCID: PMC11426226 DOI: 10.1111/aogs.14937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/30/2024] [Accepted: 07/16/2024] [Indexed: 09/27/2024]
Abstract
Relative uteroplacental insufficiency of labor (RUPI-L) is a clinical condition that refers to alterations in the fetal oxygen "demand-supply" equation caused by the onset of regular uterine activity. The term RUPI-L indicates a condition of "relative" uteroplacental insufficiency which is relative to a specific stressful circumstance, such as the onset of regular uterine activity. RUPI-L may be more prevalent in fetuses in which the ratio between the fetal oxygen supply and demand is already slightly reduced, such as in cases of subclinical placental insufficiency, post-term pregnancies, gestational diabetes, and other similar conditions. Prior to the onset of regular uterine activity, fetuses with a RUPI-L may present with normal features on the cardiotocography. However, with the onset of uterine contractions, these fetuses start to manifest abnormal fetal heart rate patterns which reflect the attempt to maintain adequate perfusion to essential central organs during episodes of transient reduction in oxygenation. If labor is allowed to continue without an appropriate intervention, progressively more frequent, and stronger uterine contractions may result in a rapid deterioration of the fetal oxygenation leading to hypoxia and acidosis. In this Commentary, we introduce the term relative uteroplacental insufficiency of labor and highlight the pathophysiology, as well as the common features observed in the fetal heart rate tracing and clinical implications.
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Affiliation(s)
- Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology UnitUniversity of ParmaParmaItaly
| | - Stefania Fieni
- Department of Medicine and Surgery, Obstetrics and Gynecology UnitUniversity of ParmaParmaItaly
| | - Ruben Ramirez Zegarra
- Department of Medicine and Surgery, Obstetrics and Gynecology UnitUniversity of ParmaParmaItaly
| | - Susana Pereira
- Fetal Medicine Unit, The Royal London HospitalBarts Health NHS TrustLondonUK
| | - Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology UnitUniversity of ParmaParmaItaly
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Scholz AS, Rónay V, Wallwiener M, Fluhr H, von Au A, Spratte J, Wallwiener S, Elsaesser M. Association between Doppler assessment and secondary cesarean delivery for intrapartum fetal compromise in small-for-gestational-age fetuses. Arch Gynecol Obstet 2024; 310:719-728. [PMID: 38789851 PMCID: PMC11258169 DOI: 10.1007/s00404-024-07559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
PURPOSE To elucidate the association between arterial and venous Doppler ultrasound parameters and the risk of secondary cesarean delivery for intrapartum fetal compromise (IFC) and neonatal acidosis in small-for-gestational-age (SGA) fetuses. METHODS This single-center, prospective, blinded, cohort study included singleton pregnancies with an estimated fetal weight (EFW) < 10th centile above 36 gestational weeks. Upon study inclusion, all women underwent Doppler ultrasound, including umbilical artery (UA) pulsatility index (PI), middle cerebral artery (MCA) PI, fetal aortic isthmus (AoI) PI, umbilical vein blood flow (UVBF), and modified myocardial performance index (mod-MPI). Primary outcome was defined as secondary cesarean section due to IFC. RESULTS In total, 87 SGA pregnancies were included, 16% of which required a cesarean section for IFC. Those fetuses revealed lower UVBF corrected for abdominal circumference (AC) (5.2 (4.5-6.3) vs 7.2 (5.5-8.3), p = 0.001). There was no difference when comparing AoI PI, UA PI, ACM PI, or mod-MPI. No association was found for neonatal acidosis. After multivariate logistic regression, UVBF/AC remained independently associated with cesarean section due to IFC (aOR 0.61 [0.37; 0.91], p = 0.03) and yielded an area under the curve (AUC) of 0.78 (95% CI, 0.67-0.89). A cut-off value set at the 50th centile of UVBF/AC reached a sensitivity of 86% and specificity of 58% for the occurrence of cesarean section due to IFC (OR 8.1; 95% CI, 1.7-37.8, p = 0.003). CONCLUSION Low levels of umbilical vein blood flow (UVBF/AC) were associated with an increased risk among SGA fetuses to be delivered by cesarean section for IFC.
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Affiliation(s)
- Anna S Scholz
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany.
| | - Vanessa Rónay
- Department of Urology, Nuernberg Hospital, Nuernberg, Germany
| | - Markus Wallwiener
- Department of Gynecology, University Hospital Halle (Saale), Halle, Germany
| | - Herbert Fluhr
- Department of Gynecology and Obstetrics, Graz University Hospital, Graz, Austria
| | - Alexandra von Au
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Julia Spratte
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
| | - Stephanie Wallwiener
- Department of Obstetrics and Fetal Medicine, University Hospital Halle (Saale), Halle, Germany
| | - Michael Elsaesser
- Department of Gynecology and Obstetrics, Heidelberg University Hospital, Im Neuenheimer Feld 440, 69120, Heidelberg, Germany
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Zhu F, Zhao Y, Wu J, Wang M, Zhu Z, Zhang L. Post-COVID-19 Fetal Cardiac Morphology and Systolic Evaluation in Infected Pregnant Women by Fetal Heart Quantification Technology. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1199-1209. [PMID: 38465462 DOI: 10.1002/jum.16444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/03/2024] [Accepted: 02/20/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Due to the government's liberalization of epidemic control, the current 2019 novel coronavirus disease (COVID-19) has started to spread widely within China. This study aimed to use the fetal heart quantification (fetal HQ) technique to assess the cardiac function and morphology of the fetuses of pregnant women diagnosed with COVID-19 in the early stages of pregnancy. METHODS Exactly 86 pregnant women diagnosed with COVID-19 infection in early pregnancy (COVID-19 group) and 90 healthy pregnant women (control group) who underwent fetal echocardiography were prospectively included in this study. The fetal HQ technique was applied to compare the differences in the global sphericity index (GSI), global strain values (GS), fractional area change (FAC), and 24-segment fractional shortening (FS) of the left and right ventricles, between the COVID-19 group and the control group. RESULTS Compared with the control group, the differences in GS and 24-segment FS of the left ventricle in the COVID-19 group were not statistically significant. However, the COVID-19 group showed lower GSI values compared with the control group (1.24 vs 1.28). FAC (48.12%) of the left ventricle and GS (-23.55%), FAC (41.74%) of the right ventricle in the COVID-19 group were reduced compared with FAC (50.50%) of the left ventricle and GS (-27.63%), FAC (46.01%) of the right ventricle in the control group. Segmental analysis revealed reduced FS in segments 20-24 in the COVID-19 group compared with the control group. Right ventricular GS was an independent predictor of adverse pregnancy outcome with an optimal cutoff value of -18.66%. CONCLUSIONS The results suggest that COVID-19 infection in early pregnancy may have a negative impact on fetal cardiac morphology and function. Fetal HQ may offer a new assessment method for the early identification of fetal cardiac alterations in pregnant women infected with COVID-19.
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Affiliation(s)
- Feihu Zhu
- Ultrasonic Department, The Third Affiliated Hospital of Zhengzhou University (Maternal and Child Health Hospital of Henan Province), Zhengzhou, China
| | - Yueshu Zhao
- Prenatal Diagnosis Center, The Third Affiliated Hospital of Zhengzhou University (Maternal and Child Health Hospital of Henan Province), Zhengzhou, China
| | - Juan Wu
- Ultrasonic Department, The Third Affiliated Hospital of Zhengzhou University (Maternal and Child Health Hospital of Henan Province), Zhengzhou, China
| | - Ming Wang
- Ultrasonic Department, The Third Affiliated Hospital of Zhengzhou University (Maternal and Child Health Hospital of Henan Province), Zhengzhou, China
| | - Ziqi Zhu
- Ultrasonic Department, The Third Affiliated Hospital of Zhengzhou University (Maternal and Child Health Hospital of Henan Province), Zhengzhou, China
| | - Lingling Zhang
- Ultrasonic Department, The Third Affiliated Hospital of Zhengzhou University (Maternal and Child Health Hospital of Henan Province), Zhengzhou, China
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Mula C, Hidalgo J, Peguero A, Mazarico E, Martinez J, Figueras F, Meler E. Third-trimester uterine artery Doppler for prediction of adverse outcome in late small-and adequate for-gestational-age fetuses. Minerva Obstet Gynecol 2023; 75:440-448. [PMID: 36943257 DOI: 10.23736/s2724-606x.23.05229-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Fetal growth restriction includes all those fetuses that do not reach their own growth potential due to placental insufficiency and therefore at higher risk of adverse perinatal outcomes. Identification and follow-up of these fetuses is essential to decrease this additional risk. Although estimated fetal weight under the 3rd centile and pathological cerebroplacental ratio are the most accepted predictive criteria, some evidence suggests that abnormal uterine artery Doppler may be a useful prognostic parameter in late-onset growth restriction fetuses at the moment of diagnosis. However, its prediction capacity as a standalone parameter is limited. In that context, integrated models of biometric and hemodynamic ultrasound parameters including uterine Doppler have been proposed as an effective approach to stratify the risk and improve perinatal outcomes. Moreover, an association of abnormal uterine artery Doppler and histological findings of placental underperfusion due to vascular obstruction has been described. Finally, it has also been suggested that the evaluation of uterine artery Doppler at third trimester in appropriate-for-gestational-age fetuses could identify cases of subclinical placental insufficiency, but further evidence is needed to define such predictive strategies.
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Affiliation(s)
- Cristina Mula
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Judit Hidalgo
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Anna Peguero
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Edurne Mazarico
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Judit Martinez
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain
| | - Francesc Figueras
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain -
| | - Eva Meler
- BCNatal - Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia Fetal (ICGON), i+D Fetal Medicine Research Center, Barcelona, Spain
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Barbieri M, Di Martino DD, Ferrazzi EM, Stampalija T. Umbilical vein blood flow: State-of-the-art. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:318-325. [PMID: 36785504 DOI: 10.1002/jcu.23412] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 06/18/2023]
Abstract
Placental blood supply to the fetus can be measured by evaluating the umbilical vein blood flow. Despite its potential application in healthcare, the umbilical vein blood flow volume is still used only in research setting. One of the reasons is a concern regarding its reproducibility, partly due to technology issues. Nowadays, technology improvements make this evaluation accurate and reproducible. The aim of this review is to refresh basic elements of the physiology of umbilical vein blood flow and its analysis. Its evaluation in normal and abnormal fetal growth is also discussed.
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Affiliation(s)
- Moira Barbieri
- Department of Mother, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Daniela Denis Di Martino
- Department of Mother, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Policlinico di Milano, Milan, Italy
| | - Enrico Mario Ferrazzi
- Department of Mother, Child and Neonate, Fondazione IRCCS Ca' Granda Ospedale Policlinico di Milano, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
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8
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Di Martino DD, Avagliano L, Ferrazzi E, Fusè F, Sterpi V, Parasiliti M, Stampalija T, Zullino S, Farina A, Bulfamante GP, Di Maso M, D’Ambrosi F. Hypertensive Disorders of Pregnancy and Fetal Growth Restriction: Clinical Characteristics and Placental Lesions and Possible Preventive Nutritional Targets. Nutrients 2022; 14:nu14163276. [PMID: 36014782 PMCID: PMC9414322 DOI: 10.3390/nu14163276] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
Background: The purpose of this study was to describe the placental lesions in pregnancies complicated by hypertensive disorders (HDP) and/or fetal growth restriction (FGR) and in uneventful control pregnancies. Methods: This is a case control study that included singleton pregnancies with HDP and normally grown fetus (HDP-AGA fetus), with HDP and FGR, early FGR, late FGR, and uneventful pregnancies. Feto-placental Doppler velocimetry and sFlt-1/PlGF ratio were performed. Placental histology was evaluated blinded according to the Amsterdam Consensus criteria. Results: Placental lesions with maternal vascular malperfusion (MVM) were significantly more frequent in HDP-FGR and early FGR (92% and 83%). MVM were significantly associated with abnormal feto-placental Doppler parameters, especially in early FGR. Delayed villous maturation (DVM) was associated with late FGR (83%). HDP-AGA fetus cases presented a heterogeneous pattern of placental lesions, including 60% of cases with MVM, but were not associated with abnormal Doppler feto-placental velocimetry. Conclusions: We found a prevalence of placental maternal vascular malperfusion in HDP-FGR and early FGR groups. These lesions were also associated with abnormal, anti-, and angiogenic markers. Conversely HDP-AGA fetus and late FGR presented more heterogeneous placental lesions not severe enough to cause feto-placental Doppler anomalies. These conditions are likely associated with different etiologies, such as maternal pre-pregnancy risk factors for metabolic syndrome. These findings suggest a possible preventive nutritional approach in addition to low-dose aspirin in pregnant women with predisposing factors for HDP-AGA fetuses and late FGR.
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Affiliation(s)
- Daniela Denis Di Martino
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Laura Avagliano
- Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy
| | - Enrico Ferrazzi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Clinical and Community Health Sciences, University of Milan, 20122 Milan, Italy
- Correspondence:
| | - Federica Fusè
- Department of Woman, Mother and Neonate, Buzzi Children’s Hospital, 20154 Milan, Italy
| | - Vittoria Sterpi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Marco Parasiliti
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34137 Trieste, Italy
- Department of Medicine, Surgery and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynaecology, Pisan University Hospital, 56124 Pisa, Italy
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery (DIMEC), Sant’Orsola-Malpighi Hospital, University of Bologna, 40126 Bologna, Italy
| | - Gaetano Pietro Bulfamante
- Department of Health Sciences, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy
- Unit of Human Pathology, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milan, Italy
| | - Matteo Di Maso
- Department of Clinical Sciences and Community Health, Branch of Medical Statistics, Biometry and Epidemiology “G.A. Maccacaro”, University of Milan, 20122 Milan, Italy
| | - Francesco D’Ambrosi
- Department of Woman, Child and Neonate, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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9
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Karge A, Lobmaier SM, Haller B, Kuschel B, Ortiz JU. Value of Cerebroplacental Ratio and Uterine Artery Doppler as Predictors of Adverse Perinatal Outcome in Very Small for Gestational Age at Term Fetuses. J Clin Med 2022; 11:jcm11133852. [PMID: 35807137 PMCID: PMC9267630 DOI: 10.3390/jcm11133852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/23/2022] [Accepted: 06/29/2022] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to evaluate the association between cerebroplacental ratio (CPR), mean uterine artery (mUtA) Doppler and adverse perinatal outcome (APO) and their predictive performance in fetuses with birth weight (BW) <3rd centile (very small for gestational age, VSGA) in comparison with fetuses with BW 3rd−10th centile (small for gestational age, SGA). This was a retrospective cohort study including singleton pregnancies delivered at term (37 + 0−41 + 6) in a single tertiary referral center over a six-year period. APO was defined as a composite of cesarean section for intrapartum fetal compromise (IFC), umbilical artery pH < 7.20, and admission to the neonatal intensive care unit for >24 h. The characteristics of the study population according to BW (VSGA and SGA) as well as the presence of composite APO were assessed. The prognostic performance of CPR and mUtA-PI was evaluated using receiver operating characteristic (ROC) analysis. In total, 203 pregnancies were included. Of these, 55 (27%) had CPR <10th centile, 25 (12%) mUtA-PI >95th centile, 65 (32%) VSGA fetuses, and 93 (46%) composite APO. VSGA showed a non-significantly higher rate of composite APO in comparison to SGA (52% vs. 43%; p = 0.202). The composite APO rate was significantly higher in SGA with CPR <10th centile (36% vs. 13%; p = 0.001), while in VSGA with CPR <10th centile was not (38% vs. 35%; p = 0.818). The composite APO rate was non-significantly higher both in VSGA (26% vs. 10%; p = 0.081) and SGA (14% vs. 6%; p = 0.742) with mUtA-PI >95th centile. The ROC analysis showed a significantly predictive value of CPR for composite APO in SGA only (AUC 0.612; p = 0.025). A low CPR was associated with composite APO in SGA fetuses. VSGA fetuses were more frequently affected by composite APO regardless of Doppler values. The predictive performance of CPR and uterine artery Doppler was poor.
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Affiliation(s)
- Anne Karge
- Division of Obstetrics and Perinatal Medicine, Department of Obstetrics and Gynecology, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (A.K.); (S.M.L.); (B.K.)
| | - Silvia M. Lobmaier
- Division of Obstetrics and Perinatal Medicine, Department of Obstetrics and Gynecology, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (A.K.); (S.M.L.); (B.K.)
| | - Bernhard Haller
- Institute of AI Medical Informatics in Medicine, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany;
| | - Bettina Kuschel
- Division of Obstetrics and Perinatal Medicine, Department of Obstetrics and Gynecology, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (A.K.); (S.M.L.); (B.K.)
| | - Javier U. Ortiz
- Division of Obstetrics and Perinatal Medicine, Department of Obstetrics and Gynecology, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany; (A.K.); (S.M.L.); (B.K.)
- Correspondence: ; Tel.: +49-89-4140-2430; Fax: +49-89-4140-2447
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10
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Tian Y, Yang X. A Review of Roles of Uterine Artery Doppler in Pregnancy Complications. Front Med (Lausanne) 2022; 9:813343. [PMID: 35308523 PMCID: PMC8927888 DOI: 10.3389/fmed.2022.813343] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/10/2022] [Indexed: 11/22/2022] Open
Abstract
The invasion of trophoblasts into the uterine decidua and decidual vessels is critical for the formation of placenta. The defects of placentation are related to the etiologies of preeclampsia (PE), fetal growth restriction (FGR), and small-for-gestational age (SGA) neonates. It is possible to predict significant vascular events during pregnancy through uterine artery Doppler (UAD). From the implantation stage to the end of pregnancy, detecting changes in uterine and placental blood vessels can provide a favorable diagnostic instrument for pregnancy complications. This review aims to collect literature about the roles of UAD in pregnancy complications. We consider all relevant articles in English from January 1, 1983 to October 30, 2021. Predicting pregnancy complications in advance allows practitioners to carry out timely interventions to avoid or lessen the harm to mothers and neonates. Administering low-dose aspirin daily before 16 weeks of pregnancy can significantly reduce the incidence of pregnancy complications. From early pregnancy to late pregnancy, UAD can combine with other maternal factors, biochemical indicators, and fetal measurement data to identify high-risk population. The identification of high-risk groups can also lessen maternal mortality. Besides, through moderate risk stratification, stringent monitoring for high-risk pregnant women can be implemented, decreasing the incidence of adversities.
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Affiliation(s)
- Yingying Tian
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
| | - Xiuhua Yang
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
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11
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Ashwal E, Ferreira F, Mei-Dan E, Aviram A, Sherman C, Zaltz A, Kingdom J, Melamed N. The accuracy of Fetoplacental Doppler in distinguishing between growth restricted and constitutionally small fetuses. Placenta 2022; 120:40-48. [DOI: 10.1016/j.placenta.2022.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 12/17/2021] [Accepted: 02/07/2022] [Indexed: 01/05/2023]
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12
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Altered erythropoiesis in newborns with congenital heart disease. Pediatr Res 2022; 91:606-611. [PMID: 33531673 DOI: 10.1038/s41390-021-01370-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Fetal hypoxia has been implicated in fetal growth restriction in congenital heart disease (CHD) and leads to stress erythropoiesis in utero. The objective is to assess erythropoiesis and its association with growth in newborns with CHD. METHODS Fetuses with prenatally diagnosed CHD from 2013 to 2018 were retrospectively reviewed. Pregnancies with multiple gestation, genetic abnormalities, major extra-cardiac anomalies, and placental abruption were excluded. Complete blood count tests at birth were compared to published normative values. Spearman correlation assessed associations of red blood cell (RBC) indices with birth anthropometrics and prenatal Doppler measures. RESULTS A total of 160 newborns were included. Median gestational age was 38.3 (37.3, 39.0) weeks. Infants ≥37 weeks gestation had lower hemoglobin (Hgb), hematocrit, and elevated nucleated RBC (nRBC), mean corpuscular volume, and mean corpuscular hemoglobin compared to reference. No differences in RBC indices were observed in infants <34 and 34-37 weeks gestation. There was no difference in Hgb and nRBC between CHD subgroups. Neither Hgb nor nRBC were associated with birth anthropometrics or Doppler patterns. CONCLUSIONS Term infants with CHD demonstrated multiple alterations in erythrocyte indices suggesting ineffective stress erythropoiesis in late gestation resulting in lower Hgb at birth. Altered erythropoiesis was not correlated to growth or Doppler patterns. IMPACT Newborns with congenital heart disease (CHD) born at term gestation demonstrated altered erythropoiesis. Term newborns with CHD have decreased hemoglobin levels despite having red blood cell indices consistent with stress erythropoiesis, suggesting an incomplete compensatory response to in utero physiologic disturbances associated with CHD. The etiology is unknown; however, it may be influenced by multiple risk factors during pregnancy in the maternal-fetal dyad. Alterations in red blood cell indices were not associated with outcomes of fetal growth.
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13
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HANSEN DN, SINDING M, PETERSEN A, CHRISTIANSEN OB, ULDBJERG N, PETERS MDA, FRØKJÆR JB, SØRENSEN A. T2* weighted placental MRI: A biomarker of placental dysfunction in small-for-gestational-age pregnancies. Am J Obstet Gynecol MFM 2022; 4:100578. [DOI: 10.1016/j.ajogmf.2022.100578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/12/2022] [Accepted: 01/27/2022] [Indexed: 11/27/2022]
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14
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van Willigen BG, van der Hout-van der Jagt MB, Huberts W, van de Vosse FN. A review study of fetal circulatory models to develop a digital twin of a fetus in a perinatal life support system. Front Pediatr 2022; 10:915846. [PMID: 36210952 PMCID: PMC9532745 DOI: 10.3389/fped.2022.915846] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Preterm birth is the main cause of neonatal deaths with increasing mortality and morbidity rates with decreasing GA at time of birth. Currently, premature infants are treated in neonatal intensive care units to support further development. However, the organs of, especially, extremely premature infants (born before 28 weeks of GA) are not mature enough to function optimally outside the womb. This is seen as the main cause of the high morbidity and mortality rates in this group. A liquid-filled incubator, a so-called PLS system, could potentially improve these numbers for extremely premature infants, since this system is designed to mimic the environment of the natural womb. To support the development and implementation of such a complex system and to interpret vital signals of the fetus during a PLS system operation, a digital twin is proposed. This mathematical model is connected with a manikin representing the digital and physical twin of the real-life PLS system. Before developing a digital twin of a fetus in a PLS system, its functional and technical requirements are defined and existing mathematical models are evaluated. METHOD AND RESULTS This review summarizes existing 0D and 1D fetal circulatory models that potentially could be (partly) adopted for integration in a digital twin of a fetus in a PLS system based on predefined requirements. The 0D models typically describe hemodynamics and/or oxygen transport during specific events, such as the transition from fetus to neonate. Furthermore, these models can be used to find hemodynamic differences between healthy and pathological physiological states. Rather than giving a global description of an entire cardiovascular system, some studies focus on specific organs or vessels. In order to analyze pressure and flow wave profiles in the cardiovascular system, transmission line or 1D models are used. As for now, these models do not include oxygen transport. CONCLUSION This study shows that none of the models identified in literature meet all the requirements relevant for a digital twin of a fetus in a PLS system. Nevertheless, it does show the potential to develop this digital twin by integrating (parts) of models into a single model.
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Affiliation(s)
- Bettine G van Willigen
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands
| | - M Beatrijs van der Hout-van der Jagt
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, Netherlands.,Signal Processing Systems, Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Wouter Huberts
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.,Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Frans N van de Vosse
- Cardiovascular Biomechanics, Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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15
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Miremberg H, Ganer Herman H, Bustan M, Weiner E, Schreiber L, Bar J, Kovo M. Placental vascular lesions differ between male and female fetuses in early-onset preeclampsia. Arch Gynecol Obstet 2021; 306:717-722. [DOI: 10.1007/s00404-021-06328-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 11/05/2021] [Indexed: 01/04/2023]
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16
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Atallah A, Butin M, Moret S, Claris O, Massoud M, Gaucherand P, Doret-Dion M. Minimum evidence-based care in intrauterine growth-restricted fetuses and neonatal prognosis. Arch Gynecol Obstet 2021; 305:1159-1168. [PMID: 34524504 DOI: 10.1007/s00404-021-06231-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Introduction: There is clear evidence that fetuses with intrauterine growth restriction (IUGR) do not receive the minimum evidence-based care during their antenatal management. OBJECTIVE Considering that optimal management of IUGR may reduce neonatal morbi-mortality in IUGR, the objective of the present study was to evaluate the impact of antenatal management of IUGR according to the recommendations of the French college of gynecologists and obstetricians (CNGOF) on the neonatal prognosis of IUGR fetuses. STUDY DESIGN From a historical cohort of 31,052 children, born at the Femme Mère Enfant hospital (Lyon, France) between January 1, 2011 and December 31, 2017, we selected the population of IUGR fetuses. The minimum evidence-based care (MEC) in the antenatal management of fetuses with IUGR was defined according to the CNGOF recommendations and neonatal prognosis of early and late IUGR fetuses were assessed based on the whether or not they received MEC. The neonatal prognosis was defined according to a composite criterion that included neonatal morbidity and mortality. RESULTS A total of 1020 fetuses with IUGR were studied. The application of MEC showed an improvement in the neonatal prognosis of early-onset IUGR (p = 0.003), and an improvement in the neonatal prognosis of IUGR born before 32 weeks (p = 0.030). Multivariate analysis confirmed the results showing an increase in neonatal morbi-mortality in early-onset IUGR in the absence of MEC with OR 1.79 (95% CI 1.01-3.19). CONCLUSION Diagnosed IUGR with MEC had a better neonatal prognosis when born before 32 weeks. Regardless of the birth term, MEC improved the neonatal prognosis of fetuses with early IUGR. Improvement in the rate of MEC during antenatal management has a significant impact on neonatal prognosis.
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Affiliation(s)
- Anthony Atallah
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France. .,Health Services and Performance Research (HESPER) EA 7425, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France.
| | - Marine Butin
- Department of Neonatalogy, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,International Center for Research in Infectiology, INSERM U1111, CNRS UMR5308, University of Lyon 1, Lyon, France
| | - Stéphanie Moret
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France
| | - Olivier Claris
- Department of Neonatalogy, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,EA 4129, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France
| | - Mona Massoud
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France
| | - Pascal Gaucherand
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,Health Services and Performance Research (HESPER) EA 7425, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France
| | - Muriel Doret-Dion
- Department of Obstetrics and Gynecology, Hospices Civils de Lyon, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.,Health Services and Performance Research (HESPER) EA 7425, University of Lyon, University Claude Bernard Lyon 1, 69008, Lyon, France
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Martinez J, Boada D, Figueras F, Meler E. How to define late fetal growth restriction. Minerva Obstet Gynecol 2021; 73:409-414. [PMID: 33904686 DOI: 10.23736/s2724-606x.21.04775-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A fraction of third-trimester small fetuses does not achieve their endowed growth potential mainly due to placental insufficiency, usually not evident in terms of impaired umbilical artery Doppler, but severe enough to increase the risk of perinatal adverse outcomes and long-term complications. The identification of those fetuses at higher-risk helps to optimize their follow-up and to decrease the risk of intrauterine demise. Several parameters can help in the identification of those fetuses at higher risk, defined as fetal growth restricted (FGR) fetuses. Severe smallness and the cerebroplacental ratio are the most consistent parameters; regarding uterine artery Doppler, although some evidence in favour has been published, there is currently no consensus about its use. Thirty-two weeks of gestation is the accepted cut-off to define late FGR. The differentiation with early FGR is necessary as these two entities have different clinical maternal manifestations, and different associated short-term and long-term neonatal outcomes. The use of angiogenic factors is promising but more research is needed on this field.
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Affiliation(s)
- Judit Martinez
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - David Boada
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Francesc Figueras
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eva Meler
- Barcelona Center for Maternal-Fetal and Neonatal Medicine, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain - .,Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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18
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Monitoring, Delivery and Outcome in Early Onset Fetal Growth Restriction. REPRODUCTIVE MEDICINE 2021. [DOI: 10.3390/reprodmed2020009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Early fetal growth restriction (FGR) remains a challenging entity associated with an increased risk of perinatal morbidity and mortality as well as maternal complications. Significant variations in clinical practice have historically characterized the management of early FGR fetuses. Nevertheless, insights into diagnosis and management options have more recently emerged. The aim of this review is to summarize the available evidence on monitoring, delivery and outcome in early-onset FGR.
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19
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Fernandez-Rodriguez B, de Alba C, Galindo A, Recio D, Villalain C, Pallas CR, Herraiz I. Obstetric and pediatric growth charts for the detection of late-onset fetal growth restriction and neonatal adverse outcomes. J Perinat Med 2021; 49:216-224. [PMID: 33027055 DOI: 10.1515/jpm-2020-0210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/11/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Late-onset fetal growth restriction (FGR) has heterogeneous prenatal and postnatal diagnostic criteria. We compared the prenatal and postnatal diagnosis of late-onset FGR and their ability to predict adverse perinatal outcomes. METHODS Retrospective cohort study of 5442 consecutive singleton pregnancies that delivered beyond 34 + 0 weeks. Prenatal diagnosis of FGR was based on customized fetal growth standards and fetal Doppler while postnatal diagnosis was based on a birthweight <3rd percentile according to newborn charts (Olsen's charts and Intergrowth 21st century programme). Perinatal outcomes were analyzed depending on whether the diagnosis was prenatal, postnatal or both. RESULTS A total of 94 out of 5442 (1.7%) were diagnosed as late-onset FGR prenatally. Olsen's chart and Intergrowth 21st chart detected that 125/5442 (2.3%) and 106/5442 (2.0%) of infants had a birthweight <3rd percentile, respectively. These charts identified 35/94 (37.2%) and 40/94 (42.6%) of the newborns with a prenatal diagnosis of late-onset FGR. Prenatally diagnosed late-onset FGR infants were at a higher risk for hypoglycemia, jaundice and polycythemia. Both prenatally and postnatally diagnosed as late-onset FGR had a higher risk for respiratory distress syndrome when compared to non-FGR. The higher risks for intensive care admission and composite adverse outcomes were observed in those with a prenatal diagnosis of late-onset FGR that was confirmed after birth. CONCLUSIONS Current definitions of pre- and postnatal late-onset FGR do not match in more than half of cases. Infants with a prenatal or postnatal diagnosis of this condition have an increased risk of neonatal morbidity even if these diagnoses are not coincident.
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Affiliation(s)
| | - Concepción de Alba
- Department of Neonatology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Alberto Galindo
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - David Recio
- Department of Neonatology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Cecilia Villalain
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Carmen Rosa Pallas
- Department of Neonatology, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
| | - Ignacio Herraiz
- Department of Obstetrics and Gynaecology, Fetal Medicine Unit-SAMID, University Hospital 12 de Octubre, 12 de Octubre Research Institute (imas12), Complutense University of Madrid, Madrid, Spain
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Kennedy LM, Tong S, Robinson AJ, Hiscock RJ, Hui L, Dane KM, Middleton AL, Walker SP, MacDonald TM. Reduced growth velocity from the mid-trimester is associated with placental insufficiency in fetuses born at a normal birthweight. BMC Med 2020; 18:395. [PMID: 33357243 PMCID: PMC7758928 DOI: 10.1186/s12916-020-01869-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/24/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Fetal growth restriction (FGR) due to placental insufficiency is a major risk factor for stillbirth. While small-for-gestational-age (SGA; weight < 10th centile) is a commonly used proxy for FGR, detection of FGR among appropriate-for-gestational-age (AGA; weight ≥ 10th centile) fetuses remains an unmet need in clinical care. We aimed to determine whether reduced antenatal growth velocity from the time of routine mid-trimester ultrasound is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency among term AGA infants. METHODS Three hundred and five women had biometry measurements recorded from their routine mid-trimester (20-week) ultrasound, at 28 and 36 weeks' gestation, and delivered an AGA infant. Mid-trimester, 28- and 36-week estimated fetal weight (EFW) and abdominal circumference (AC) centiles were calculated. The EFW and AC growth velocities between 20 and 28 weeks, and 20-36 weeks, were examined as predictors of four clinical indicators of placental insufficiency: (i) low 36-week cerebroplacental ratio (CPR; CPR < 5th centile reflects cerebral redistribution-a fetal adaptation to hypoxia), (ii) neonatal acidosis (umbilical artery pH < 7.15) after the hypoxic challenge of labour, (iii) low neonatal body fat percentage (BF%) reflecting reduced nutritional reserve and (iv) placental weight < 10th centile. RESULTS Declining 20-36-week fetal growth velocity was associated with all indicators of placental insufficiency. Each one centile reduction in EFW between 20 and 36 weeks increased the odds of cerebral redistribution by 2.5% (odds ratio (OR) = 1.025, P = 0.001), the odds of neonatal acidosis by 2.7% (OR = 1.027, P = 0.002) and the odds of a < 10th centile placenta by 3.0% (OR = 1.030, P < 0.0001). Each one centile reduction in AC between 20 and 36 weeks increased the odds of neonatal acidosis by 3.1% (OR = 1.031, P = 0.0005), the odds of low neonatal BF% by 2.8% (OR = 1.028, P = 0.04) and the odds of placenta < 10th centile by 2.1% (OR = 1.021, P = 0.0004). Falls in EFW or AC of > 30 centiles between 20 and 36 weeks were associated with two-threefold increased relative risks of these indicators of placental insufficiency, while low 20-28-week growth velocities were not. CONCLUSIONS Reduced growth velocity between 20 and 36 weeks among AGA fetuses is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency. These fetuses potentially represent an important, under-recognised cohort at increased risk of stillbirth. Encouragingly, this novel fetal assessment would require only one additional ultrasound to current routine care, and adds to the potential benefits of routine 36-week ultrasound.
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Affiliation(s)
- Lucy M Kennedy
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Alice J Robinson
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Richard J Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Kirsten M Dane
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Anna L Middleton
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Teresa M MacDonald
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia. .,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.
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21
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Rizzo G, Mappa I, Bitsadze V, Słodki M, Khizroeva J, Makatsariya A, D'Antonio F. Role of Doppler ultrasound at time of diagnosis of late-onset fetal growth restriction in predicting adverse perinatal outcome: prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:793-798. [PMID: 31343783 DOI: 10.1002/uog.20406] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 06/02/2019] [Accepted: 07/11/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Pregnancies complicated by late-onset fetal growth restriction (FGR) are at increased risk of short- and long-term morbidities. Despite this, identification of cases at higher risk of adverse perinatal outcome, at the time of FGR diagnosis, is challenging. The aims of this study were to elucidate the strength of association between fetoplacental Doppler indices at the time of diagnosis of late-onset FGR and adverse perinatal outcome, and to determine their predictive accuracy. METHODS This was a prospective study of consecutive singleton pregnancies complicated by late-onset FGR. Late-onset FGR was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 3rd centile, or EFW or AC < 10th centile and umbilical artery (UA) pulsatility index (PI) > 95th centile or cerebroplacental ratio (CPR) < 5th centile, diagnosed after 32 weeks. EFW, uterine artery PI, UA-PI, fetal middle cerebral artery (MCA) PI, CPR and umbilical vein blood flow normalized for fetal abdominal circumference (UVBF/AC) were recorded at the time of the diagnosis of FGR. Doppler variables were expressed as Z-scores for gestational age. Composite adverse perinatal outcome was defined as the occurrence of at least one of emergency Cesarean section for fetal distress, 5-min Apgar score < 7, umbilical artery pH < 7.10 and neonatal admission to the special care unit. Logistic regression analysis was used to elucidate the strength of association between different ultrasound parameters and composite adverse perinatal outcome, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive accuracy. RESULTS In total, 243 consecutive singleton pregnancies complicated by late-onset FGR were included. Composite adverse perinatal outcome occurred in 32.5% (95% CI, 26.7-38.8%) of cases. In pregnancies with composite adverse perinatal outcome, compared with those without, mean uterine artery PI Z-score (2.23 ± 1.34 vs 1.88 ± 0.89, P = 0.02) was higher, while Z-scores of UVBF/AC (-1.93 ± 0.88 vs -0.89 ± 0.94, P ≤ 0.0001), MCA-PI (-1.56 ± 0.93 vs -1.22 ± 0.84, P = 0.004) and CPR (-1.89 ± 1.12 vs -1.44 ± 1.02, P = 0.002) were lower. On multivariable logistic regression analysis, Z-scores of mean uterine artery PI (P = 0.04), CPR (P = 0.002) and UVBF/AC (P = 0.001) were associated independently with composite adverse perinatal outcome. UVBF/AC Z-score had an area under the ROC curve (AUC) of 0.723 (95% CI, 0.64-0.80) for composite adverse perinatal outcome, demonstrating better accuracy than that of mean uterine artery PI Z-score (AUC, 0.593; 95% CI, 0.50-0.69) and CPR Z-score (AUC, 0.615; 95% CI, 0.52-0.71). A multiparametric prediction model including Z-scores of MCA-PI, uterine artery PI and UVBF/AC had an AUC of 0.745 (95% CI, 0.66-0.83) for the prediction of composite adverse perinatal outcome. CONCLUSION While CPR and uterine artery PI assessed at the time of diagnosis are associated independently with composite adverse perinatal outcome in pregnancies complicated by late-onset FGR, their diagnostic performance for composite adverse perinatal outcome is low. UVBF/AC showed better accuracy for prediction of composite adverse perinatal outcome, although its usefulness in clinical practice as a standalone predictor of adverse pregnancy outcome requires further research. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Rizzo
- Division of Maternal Fetal Medicine, Ospedale Cristo Re, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - I Mappa
- Division of Maternal Fetal Medicine, Ospedale Cristo Re, Università di Roma Tor Vergata, Rome, Italy
| | - V Bitsadze
- Division of Maternal Fetal Medicine, Ospedale Cristo Re, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - M Słodki
- Faculty of Health Sciences, The State University of Applied Sciences in Płock, Płock, Poland
- Department of Prenatal Cardiology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - J Khizroeva
- Division of Maternal Fetal Medicine, Ospedale Cristo Re, Università di Roma Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Makatsariya
- Department of Obstetrics and Gynecology, The First I. M. Sechenov Moscow State Medical University, Moscow, Russia
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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Martinez-Portilla RJ, Caradeux J, Meler E, Lip-Sosa DL, Sotiriadis A, Figueras F. Third-trimester uterine artery Doppler for prediction of adverse outcome in late small-for-gestational-age fetuses: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:575-585. [PMID: 31785172 DOI: 10.1002/uog.21940] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 11/18/2019] [Accepted: 11/22/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the predictive ability for adverse perinatal outcome of abnormal third-trimester uterine artery Doppler in late small-for-gestational-age (SGA) fetuses. METHODS A systematic search was performed to identify relevant observational studies and randomized controlled trials evaluating the performance of abnormal third-trimester uterine artery Doppler for the prediction of adverse perinatal outcome in suspected SGA fetuses and SGA neonates. Abnormal uterine artery Doppler was defined as uterine artery pulsatility index > 95th percentile or ≥ 2 SD above the mean, or bilateral uterine artery notching. Hierarchical summary receiver-operating-characteristics (ROC) curves were constructed using random-effects modeling. Bayesian analysis was used to calculate the posterior probability of adverse perinatal outcome following an abnormal or normal uterine artery Doppler assessment. RESULTS Seventeen observational studies (including 7552 fetuses either diagnosed with suspected SGA (n = 3461) or later diagnosed as a SGA neonate (n = 4091)) met the inclusion criteria; no randomized-controlled trials met the inclusion criteria. Summary ROC curves showed that, among suspected SGA fetuses, the best predictive accuracy of abnormal third-trimester uterine artery Doppler was for perinatal mortality and the worst was for composite adverse perinatal outcome, with areas under the summary ROC curves of 0.90 and 0.66, respectively. The corresponding positive and negative likelihood ratios were 16.5 and 0.6 for perinatal mortality and 2.82 and 0.65 for composite adverse perinatal outcome, respectively. Following an abnormal vs normal uterine artery Doppler assessment, the posterior risks for composite adverse perinatal outcome, admission to the neonatal intensive care unit, Cesarean section for intrapartum fetal compromise, 5-min Apgar score < 7, neonatal acidosis and perinatal death were: 52.3% vs 20.2%, 48.6% vs 18.7%, 23.1% vs 15.2%, 3.59% vs 1.32%, 9.15% vs 5.12% and 31.4% vs 1.64%, respectively. CONCLUSION Abnormal uterine artery Doppler in the third trimester appears to be moderately useful in predicting perinatal death in pregnancies with suspected SGA. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R J Martinez-Portilla
- Fetal Medicine Research Center, BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Health Sciences, University of Oxford, Oxford, UK
| | - J Caradeux
- Fetal Medicine Unit, Clínica Dávila, Santiago, Chile
| | - E Meler
- Fetal Medicine Research Center, BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - D L Lip-Sosa
- Fetal Medicine Research Center, BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - A Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - F Figueras
- Fetal Medicine Research Center, BCNatal Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Institut Clínic de Ginecologia, Obstetricia i Neonatologia, Universitat de Barcelona, Barcelona, Catalonia, Spain
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23
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Perry H, Lehmann H, Mantovani E, Thilaganathan B, Khalil A. Are maternal hemodynamic indices markers of fetal growth restriction in pregnancies with a small-for-gestational-age fetus? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:210-216. [PMID: 31381215 DOI: 10.1002/uog.20419] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 07/27/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Pregnancies complicated by fetal growth restriction (FGR) have a worse outcome than those with a small-for-gestational-age (SGA) fetus. There is increasing evidence of a maternal cardiovascular role in the pathophysiology of FGR. We aimed to compare maternal hemodynamic indices between pregnancies complicated by FGR and those delivering a SGA neonate, using a non-invasive device. METHODS This was a prospective study of normotensive pregnancies complicated by FGR (defined as estimated fetal weight (EFW) < 3rd centile or Doppler evidence of impaired placental-fetal blood flow), those with a SGA fetus (defined as EFW < 10th centile) and control pregnancies with an appropriately grown fetus. Assessment of maternal hemodynamics (heart rate (HR), cardiac output (CO), mean arterial pressure (MAP), systemic vascular resistance (SVR) and stroke volume) was performed using a non-invasive device (USCOM-1A®). Uterine artery (UtA) pulsatility index (PI) was measured using transabdominal ultrasound. Hemodynamic variables that are affected by gestational age and maternal characteristics were corrected for using device-specific reference ranges. Comparison between groups was performed using the chi-square test or the Mann-Whitney U-test, as appropriate. RESULTS A total of 102 FGR, 64 SGA and 401 control pregnancies, with a median gestational age of 36 weeks, were included in the analysis. Women with a pregnancy complicated by FGR and those with a SGA fetus were shorter and weighed less than did controls. Compared with controls, the FGR group had significantly lower median maternal HR (80 beats per min (bpm) vs 85 bpm; P = 0.001) and CO multiples of the median (MoM; 0.91 vs 0.98; P = 0.003), and higher median maternal MAP (90 mmHg vs 87 mmHg; P = 0.040), SVR MoM (1.2 vs 1.0; P < 0.001) and UtA-PI MoM (1.1 vs 0.96; P < 0.001), but there was no significant difference in stroke volume MoM (1.0 vs 0.98; P = 0.647). Compared with the SGA group, the FGR group had a significantly lower median HR (80 bpm vs 87 bpm; P = 0.022), and higher median maternal MAP (90 mmHg vs 85 mmHg; P = 0.025), SVR MoM (1.2 vs 1.0; P = 0.002) and UtA-PI MoM (1.1 vs 0.98; P = 0.005), but there was no significant difference in CO MoM (0.91 vs 0.96; P = 0.092) or stroke volume MoM (1.0 vs 1.0; P = 0.806). There were no significant differences in adjusted maternal hemodynamic indices between the SGA group and controls. CONCLUSION Pregnancies complicated by FGR presented with impaired maternal hemodynamic function, as evidenced by lower HR and CO, as well as higher MAP, SVR and UtA resistance. Pregnancies delivering a SGA neonate, without evidence of FGR, had normal maternal hemodynamic function. Maternal hemodynamic indices may therefore be of value in distinguishing FGR from SGA pregnancies. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - H Lehmann
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - E Mantovani
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
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Abstract
Placental dysfunction is a major contributing factor to fetal growth restriction. Placenta-mediated fetal growth restriction occurs through chronic fetal hypoxia owing to poor placental perfusion through a variety of mechanisms. Maternal vascular malperfusion is the most common placental disease contributing to fetal growth restriction; however, the role of rare placental diseases should not be overlooked. Although the features of maternal vascular malperfusion are identifiable on placental pathology, antepartum diagnostic methods are evolving. Placental imaging and uterine artery Doppler, used in conjunction with angiogenic growth factors (specifically placenta growth factor and soluble fms-like tyrosine kinase-1), play an increasingly important role.
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25
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Paules C, Youssef L, Rovira C, Crovetto F, Nadal A, Peguero A, Figueras F, Eixarch E, Crispi F, Miranda J, Gratacós E. Distinctive patterns of placental lesions in pre-eclampsia vs small-for-gestational age and their association with fetoplacental Doppler. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:609-616. [PMID: 31115105 DOI: 10.1002/uog.20350] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/03/2019] [Accepted: 05/10/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To describe placental histopathological findings in a large cohort of pregnancies complicated by pre-eclampsia (PE) and/or small-for-gestational age (SGA), and to investigate their association with fetoplacental Doppler parameters. METHODS This was a prospective observational study of normotensive pregnancies with SGA (defined as birth weight < 10th centile) (n = 184), PE pregnancies with a normally grown fetus (n = 102), pregnancies with both PE and SGA (n = 120) and uncomplicated pregnancies (n = 202). Uterine (UtA), umbilical (UA) and fetal middle cerebral (MCA) artery pulsatility indices (PI) were assessed. The cerebroplacental ratio (CPR) was calculated by dividing MCA-PI by UA-PI. Doppler parameters were considered abnormal when UtA-PI or UA-PI was > 95th centile or MCA-PI or CPR was < 5th centile. Placental lesions were categorized as vascular (maternal or fetal side), immunoinflammatory or other, according to the 2014 Amsterdam Placental Workshop Group Consensus Statement. Comparison between the study groups was performed using univariate and multiple regression analysis, and logistic regression was used to determine the relationship between abnormal Doppler parameters and placental lesions. RESULTS Maternal-side vascular lesions were significantly more common in PE pregnancies with SGA than in the other groups (PE + SGA, 73% vs PE, 46% vs SGA, 38% vs controls, 31%; P = 0.01) and included mainly two types of lesion: developmental (PE + SGA, 13% vs PE, 5% vs SGA, 3% vs controls, 1.5%; P < 0.001) and malperfusion (PE + SGA, 70% vs PE, 39% vs SGA, 32% vs controls, 25%; P = 0.001). In contrast, the incidence of fetal-side developmental lesions was significantly higher in normotensive SGA pregnancies than in controls and PE pregnancies (PE + SGA, 0% vs PE, 3% vs SGA, 8% vs controls, 2%; P = 0.001). All cases displayed a lower prevalence of infectious lesions than did controls, with the highest prevalence of immune lesions observed in pregnancies with both PE and SGA (PE + SGA, 18% vs PE, 8% vs SGA, 10% vs controls, 9%; P = 0.001). All fetoplacental Doppler parameters evaluated were associated with maternal-side vascular lesions, mainly malperfusion (mean UtA-PI: odds ratio (OR), 2.45 (95% CI, 1.51-3.97); UA-PI: OR, 2.05 (95% CI, 1.02-4.47); MCA-PI: OR, 2.75 (95% CI, 1.40-5.42); CPR: OR, 1.75 (95% CI, 1.04-2.95)). This association was evident mainly in the normotensive SGA group, being non-significant in controls or PE pregnancies without SGA. No significant associations were observed between fetoplacental Doppler parameters and other placental lesions in any of the study groups. CONCLUSIONS PE and SGA are associated with different patterns of placental histopathological lesions in accordance with the clinical manifestation of the placental disorder (maternal vs fetal). Fetoplacental Doppler findings show an association with placental malperfusion lesions on the maternal side, supporting the use of abnormal Doppler as a surrogate for placental insufficiency. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- C Paules
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - L Youssef
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - C Rovira
- Department of Pathology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - F Crovetto
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - A Nadal
- Department of Pathology, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - A Peguero
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Figueras
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - E Eixarch
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Crispi
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - J Miranda
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - E Gratacós
- Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital Sant Joan de Déu, Institut Clínic de Ginecologia, Obstetricia i Neonatologia, IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Ravikumar G, Crasta J. Do Doppler Changes Reflect Pathology of Placental Vascular Lesions in IUGR Pregnancies? Pediatr Dev Pathol 2019; 22:410-419. [PMID: 30894076 DOI: 10.1177/1093526619837790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Doppler assessment of uteroplacental (UP) and fetoplacental (FP) circulation detects abnormal waveforms in intrauterine growth-restricted (IUGR) pregnancies. Similarly, histopathology also reveals lesions of vascular compromise in IUGR placenta. We evaluated an association between Doppler and histopathological (HP) assessment of the maternal and fetal circulation in IUGR. METHODS IUGR cases with both Doppler and histopathology assessment were selected from our database. Doppler patterns recorded UP and FP insufficiency. The HP vascular lesions were classified as maternal vascular underperfusion and fetal thrombotic vasculopathy (FTV). IUGRs were grouped based on (i) presence of preeclampsia (PE), (ii) clinical onset (early vs late) of IUGR (early onset [EO]/late onset), and (iii) gestational age (term, T/preterm, PT). RESULTS Abnormal Doppler waveforms were present in 69 of the total 88 IUGR cases (78.4%). The most frequent pattern was fetoplacental insufficiency (FPI) (66%) which was combined with uteroplacental insufficiency (UPI) in 49%. HP showed vascular lesions in 52.3% and most frequent was FTV (38%). PE-associated IUGR (n = 49) had higher UPI pattern (75.5% vs 43.6%, P = .004), while normotensive IUGR had higher FPI pattern (28.2% vs 8.2%, P = .01). EO-IUGR (n = 55) and PT-IUGR (n = 52) had significant abnormal Doppler waveforms (P < .05) with higher combined patterns and brain sparing. Doppler was more sensitive for fetal vascular lesions than maternal (75.8% vs 66.7%). However, 42% of cases with normal Doppler findings showed HP vascular lesions. CONCLUSION IUGR pregnancies harbor significant vascular compromise. Fetal circulatory lesions were more common in IUGR pregnancies. In a significant number of cases with normal Doppler report, vascular lesions were identified on histopathology, emphasizing placental examination in all cases of IUGR.
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Affiliation(s)
- Gayatri Ravikumar
- Department of Pathology, St. John's Medical College, Bangalore, Karnataka, India
| | - Julian Crasta
- Department of Pathology, St. John's Medical College, Bangalore, Karnataka, India
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27
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Leite DFB, Cecatti JG. Fetal Growth Restriction Prediction: How to Move beyond. ScientificWorldJournal 2019; 2019:1519048. [PMID: 31530999 PMCID: PMC6721475 DOI: 10.1155/2019/1519048] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 08/01/2019] [Indexed: 12/16/2022] Open
Abstract
The actual burden and future burden of the small-for-gestational-age (SGA) babies turn their screening in pregnancy a question of major concern for clinicians and policymakers. Half of stillbirths are due to growth restriction in utero, and possibly, a quarter of livebirths of low- and middle-income countries are SGA. Growing body of evidence shows their higher risk of adverse outcomes at any period of life, including increased rates of neurologic delay, noncommunicable chronic diseases (central obesity and metabolic syndrome), and mortality. Although there is no consensus regarding its definition, birthweight centile threshold, or follow-up, we believe birthweight <10th centile is the most suitable cutoff for clinical and epidemiological purposes. Maternal clinical factors have modest predictive accuracy; being born SGA appears to be of transgenerational heredity. Addition of ultrasound parameters improves prediction models, especially using estimated fetal weight and abdominal circumference in the 3rd trimester of pregnancy. Placental growth factor levels are decreased in SGA pregnancies, and it is the most promising biomarker in differentiating angiogenesis-related SGA from other causes. Unfortunately, however, only few societies recommend universal screening. SGA evaluation is the first step of a multidimensional approach, which includes adequate management and long-term follow-up of these newborns. Apart from only meliorating perinatal outcomes, we hypothesize SGA screening is a key for socioeconomic progress.
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Affiliation(s)
- Debora F. B. Leite
- Department of Obstetrics and Gynecology, University of Campinas, School of Medical Sciences, Campinas, Sao Paulo, Brazil
- Federal University of Pernambuco, Caruaru, Pernambuco, Brazil
- Clinics Hospital of the Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - Jose G. Cecatti
- Department of Obstetrics and Gynecology, University of Campinas, School of Medical Sciences, Campinas, Sao Paulo, Brazil
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Morales-Roselló J, Buongiorno S, Loscalzo G, Abad García C, Cañada Martínez AJ, Perales Marín A. Does Uterine Doppler Add Information to the Cerebroplacental Ratio for the Prediction of Adverse Perinatal Outcome at the End of Pregnancy? Fetal Diagn Ther 2019; 47:34-44. [PMID: 31137027 DOI: 10.1159/000499483] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/07/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate whether the addition of the mean uterine arteries pulsatility index (mUtA PI) to the cerebroplacental ratio (CPR) improves its ability to predict adverse perinatal outcome (APO) at the end of pregnancy. METHODS This was a prospective study of 891 fetuses that underwent an ultrasound examination at 34-41 weeks. The CPR and the mUtA PI were converted into multiples of the median (MoM) and the estimated fetal weight (EFW) into centiles according to local references. APO was defined as a composite of abnormal cardiotocogram, intrapartum pH requiring cesarean section, 5' Apgar score <7, neonatal pH <7.10 and admission to pediatric care units. The accuracies of the different parameters were evaluated alone and in combination with gestational characteristics using univariate and multivariate analyses by means of the Akaike Information Criteria (AIC) and the area under the curve (AUC). Finally, a comparison was similarly performed between the CPR and the cerebro-placental-uterine ratio (CPUR; CPR/mUtA PI) for the prediction of APO. RESULTS The univariate analysis showed that CPR MoM was the best parameter predicting APO (AIC 615.71, AUC 0.675). The multivariate analysis including clinical data showed that the best prediction was also achieved with the CPR MoM (AIC 599.39, AUC 0.718). Moreover, when EFW centiles were considered, the addition of UtA PI MoM did not improve the prediction already obtained with CPR MoM (AIC 591.36, AUC 0.729 vs. AIC 589.86, AUC 0.731). Finally, the prediction by means of CPUR did not improve that of CPR alone (AIC 623.38, AUC 0.674 vs. AIC 623.27, AUC 0.66). CONCLUSION The best prediction of APO at the end of pregnancy is obtained with CPR whatever is the combination of parameters. The addition of uterine Doppler to the information yielded by CPR does not result in any prediction improvement.
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Affiliation(s)
- José Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain, .,Department of Pediatrics, Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain,
| | - Silvia Buongiorno
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Gabriela Loscalzo
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Cristina Abad García
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Alfredo Perales Marín
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain.,Department of Pediatrics, Obstetrics and Gynecology, Universidad de Valencia, Valencia, Spain
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29
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Dall'Asta A, Ghi T, Rizzo G, Cancemi A, Aloisio F, Arduini D, Pedrazzi G, Figueras F, Frusca T. Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:481-487. [PMID: 29900608 DOI: 10.1002/uog.19113] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/28/2018] [Accepted: 06/01/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies. METHODS This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome. RESULTS Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P = 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10th percentile compared to those with CPR MoM ≥ 10th percentile (6/54 (11.1%) vs 19/508 (3.7%); P = 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively). CONCLUSIONS Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Dall'Asta
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - T Ghi
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - A Cancemi
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - F Aloisio
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
| | - D Arduini
- Department of Obstetrics and Gynecology, Casa di Cura Santa Famiglia, University of Rome Tor Vergata, Rome, Italy
| | - G Pedrazzi
- Department of Medicine and Surgery & Robust Statistics Academy (Ro.S.A.), University of Parma, Parma, Italy
| | - F Figueras
- Fetal i+D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Barcelona, Spain
| | - T Frusca
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and Gynecology, University of Parma, Parma, Italy
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Aviram A, Sherman C, Kingdom J, Zaltz A, Barrett J, Melamed N. Defining early vs late fetal growth restriction by placental pathology. Acta Obstet Gynecol Scand 2018; 98:365-373. [PMID: 30372519 DOI: 10.1111/aogs.13499] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 10/21/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Although early and late fetal growth restriction have been suggested to be distinct entities, the optimal gestational age cut-off that differentiates the two conditions is currently unclear and has been arbitrarily set in previous studies between 32 and 37 weeks. We aimed to use placental pathology findings to determine that optimal gestational age cut-off between early and late fetal growth restriction. MATERIAL AND METHODS A retrospective cohort study of all women with singleton gestation who gave birth to a neonate diagnosed as small-for-gestational age (small-for-gestational age, defined as birthweight <10th percentile for gestational age) at a tertiary referral center between January 2001 and December 2015, and for whom placental pathology was available. Placental abnormalities were classified into lesions associated with maternal vascular malperfusion (MVM), fetal vascular malperfusion, placental hemorrhage and chronic villitis. Placental findings were analyzed as a function of gestational age at birth. The analysis was repeated in the subgroups of women without hypertensive complications of pregnancy (to reflect changes associated with isolated small-for-gestational age) and of neonates with severe small-for-gestational age (defined as birthweight <5th percentile), which are more likely to represent true fetal growth restriction. RESULTS A total of 895 women met the inclusion criteria. The only histological finding that changed with gestational age was MVM pathology, which decreased in frequency with increasing gestational age. We identified a considerable drop in the rate of MVM lesions at 33 weeks of gestation. The rate of MVM pathology in placentas of infants born before 330/7 weeks was significantly higher than that observed in placentas of infants born at 330/7 weeks or longer: 71.6% vs 27.4%, P < 0.001 for ≥2 MVM lesions, and 35.5% vs 3.5%, P < 0.001 for ≥3 MVM lesions. These findings persisted in the subgroups of women without hypertensive complications of pregnancy (n = 662) and of neonates with severe small-for-gestational age (n = 464). CONCLUSIONS Using placental pathology as a direct measure of the mechanisms underlying fetal growth restriction, the optimal gestational age at birth cut-off which differentiates early from late fetal growth restriction appears to be 330/7 weeks.
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Affiliation(s)
- Amir Aviram
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.,The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Christopher Sherman
- Division of Anatomic Pathology, Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Center , University of Toronto, Toronto, Ontario, Canada
| | - John Kingdom
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Arthur Zaltz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Jon Barrett
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Nir Melamed
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
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31
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Kwiatkowski S, Bednarek-Jędrzejek M, Ksel J, Tousty P, Kwiatkowska E, Cymbaluk A, Rzepka R, Chudecka-Głaz A, Dołęgowska B, Torbè A. sFlt-1/PlGF and Doppler ultrasound parameters in SGA pregnancies with confirmed neonatal birth weight below 10th percentile. Pregnancy Hypertens 2018; 14:79-85. [PMID: 30527123 DOI: 10.1016/j.preghy.2018.08.448] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/02/2018] [Accepted: 08/15/2018] [Indexed: 11/30/2022]
Abstract
We explored whether there was a relationship between the sFlt-1/PlGF ratio in early-late and late-onset SGA patients and whether it is associated with neonatal birth weight. MATERIAL/METHODS 110 patients who were diagnosed with a fetal weight below the 10th percentile for gestational age and who at the same time delivered neonates with a birth weight below the 10th percentile for gestational age. For each of the patients sFlt-1, PlGF and the sFlt-1/PlGF ratio were studied and uterine artery (UtA) and umbilical artery (UA) Doppler were performed. RESULTS sFlt-1/PlGF ratios and neonatal birth weight which showed significant negative correlation across the entire population studied (R = -0.46, p < 0.001). In late-onset SGA patients this negative correlation was observed, as well (R = -0.54, p < 0.001) In the group of patients with pregnancies older than 34 weeks and an sFlt-1/PlGF ratio ≥38, we observed a significantly lower neonatal birth weight when compared to the same gestational age group with an sFlt-1/PlGF ratio <38 (2045 g vs 2405 g, p < 0.001). CONCLUSION Late-onset SGA syndromes are characterized by lower sFlt-1/PlGF ratios, which indicates a lower degree of placental function impairment. The sFlt-1/PlGF ratio can be a predictor of more significant growth disorders and a lower neonatal birth weight. The sFlt-1/PlGF ratio can be helpful in distinguishing between disordered angiogenesis-dependent and other causes of late-onset SGA cases.
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Affiliation(s)
- Sebastian Kwiatkowski
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland.
| | | | - Joanna Ksel
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland
| | - Piotr Tousty
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland
| | - Ewa Kwiatkowska
- Department of Nephrology, Transplantology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Aneta Cymbaluk
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University, Szczecin, Poland
| | - Rafał Rzepka
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland
| | - Anita Chudecka-Głaz
- Department of Gynecological Surgery and Gynecological Oncology of Adults and Adolescents, Pomeranian Medical University, Szczecin, Poland
| | - Barbara Dołęgowska
- Department of Microbiology, Immunology and Laboratory Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Andrzej Torbè
- Department of Obstetrics and Gynecology, Pomeranian Medical University, Szczecin, Poland
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Morales-Roselló J. Re: De-novo abnormal uteroplacental circulation in third trimester: pregnancy outcome and pathological implications. J. Binder, C. Monaghan, B. Thilaganathan, S. Carta and A. Khalil. Ultrasound Obstet Gynecol 2018; 52: 60-65. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:10. [PMID: 29974593 DOI: 10.1002/uog.19103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- J Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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Morales-Roselló J, Khalil A, Fornés-Ferrer V, Perales-Marín A. Accuracy of the fetal cerebroplacental ratio for the detection of intrapartum compromise in nonsmall fetuses. J Matern Fetal Neonatal Med 2018. [DOI: 10.1080/14767058.2018.1450380] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- José Morales-Roselló
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Departamento de Pediatría Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain
| | - Asma Khalil
- Fetal Medicine Unit, St. George’s Hospital and St George’s University, London, United Kingdom
| | | | - Alfredo Perales-Marín
- Servicio de Obstetricia, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Departamento de Pediatría Obstetricia y Ginecología, Universidad de Valencia, Valencia, Spain
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Rial-Crestelo M, Martinez-Portilla RJ, Cancemi A, Caradeux J, Fernandez L, Peguero A, Gratacos E, Figueras F. Added value of cerebro-placental ratio and uterine artery Doppler at routine third trimester screening as a predictor of SGA and FGR in non-selected pregnancies. J Matern Fetal Neonatal Med 2018; 32:2554-2560. [DOI: 10.1080/14767058.2018.1441281] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- M. Rial-Crestelo
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
| | - R. J. Martinez-Portilla
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Valencia, Spain
- Fetal Medicine Unit, Clínica Hospital Sinaí, Xalapa Veracruz, México
| | - A. Cancemi
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
| | - J. Caradeux
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Valencia, Spain
- Fetal Medicine Unit, Clínica Hospital Sinaí, Xalapa Veracruz, México
- Fetal Medicine Unit, Clínica Dávila, Santiago, Chile
| | - L. Fernandez
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
| | - A. Peguero
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
| | - E. Gratacos
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Valencia, Spain
| | - Francesc Figueras
- Fetal i + D Fetal Medicine Research Centre, BCNatal, Barcelona Centre for Maternal–Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu, IDIBAPS), University of Barcelona, Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Valencia, Spain
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Planning management and delivery of the growth-restricted fetus. Best Pract Res Clin Obstet Gynaecol 2018; 49:53-65. [PMID: 29606482 DOI: 10.1016/j.bpobgyn.2018.02.009] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 02/23/2018] [Accepted: 02/23/2018] [Indexed: 11/22/2022]
Abstract
A uniform approach to management of fetal growth restriction (FGR) improves outcome, prevents stillbirth, and allows appropriately timed delivery. An estimated fetal weight below the tenth percentile with coexisting abnormal umbilical artery (UA), middle cerebral artery (MCA), or cerebroplacental ratio Doppler index best identifies the small fetus requiring surveillance. Placental perfusion defects are more common earlier in gestation; accordingly, early-onset (≤32 weeks of gestation) and late-onset (>32 weeks) FGR differ in clinical phenotype. In early-onset FGR, progression of UA Doppler abnormality determines clinical acceleration, while abnormal ductus venosus (DV) Doppler precedes deterioration of biophysical variables and stillbirth. Accordingly, late DV Doppler changes, abnormal biophysical variables, or an abnormal cCTG require delivery. In late-onset FGR, MCA Doppler abnormalities precede deterioration and stillbirth. However, from 34 to 38 weeks, randomized evidence on optimal delivery timing is lacking. From 38 weeks onward, the balance of neonatal versus fetal risks favors delivery.
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Figueras F, Caradeux J, Crispi F, Eixarch E, Peguero A, Gratacos E. Diagnosis and surveillance of late-onset fetal growth restriction. Am J Obstet Gynecol 2018; 218:S790-S802.e1. [PMID: 29422212 DOI: 10.1016/j.ajog.2017.12.003] [Citation(s) in RCA: 177] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/16/2017] [Accepted: 12/01/2017] [Indexed: 11/18/2022]
Abstract
By consensus, late fetal growth restriction is that diagnosed >32 weeks. This condition is mildly associated with a higher risk of perinatal hypoxic events and suboptimal neurodevelopment. Histologically, it is characterized by the presence of uteroplacental vascular lesions (especially infarcts), although the incidence of such lesions is lower than in preterm fetal growth restriction. Screening procedures for fetal growth restriction need to identify small babies and then differentiate between those who are healthy and those who are pathologically small. First- or second-trimester screening strategies provide detection rates for late smallness for gestational age <50% for 10% of false positives. Compared to clinically indicated ultrasonography in the third trimester, universal screening triples the detection rate of late smallness for gestational age. As opposed to early third-trimester ultrasound, scanning late in pregnancy (around 37 weeks) increases the detection rate for birthweight <3rd centile. Contrary to early fetal growth restriction, umbilical artery Doppler velocimetry alone does not provide good differentiation between late smallness for gestational age and fetal growth restriction. A combination of biometric parameters (with severe smallness usually defined as estimated fetal weight or abdominal circumference <3rd centile) with Doppler criteria of placental insufficiency (either in the maternal [uterine Doppler] or fetal [cerebroplacental ratio] compartments) offers a classification tool that correlates with the risk for adverse perinatal outcome. There is no evidence that induction of late fetal growth restriction at term improves perinatal outcomes nor is it a cost-effective strategy, and it may increase neonatal admission when performed <38 weeks.
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Affiliation(s)
- Francesc Figueras
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain.
| | - Javier Caradeux
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Fatima Crispi
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Elisenda Eixarch
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Anna Peguero
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
| | - Eduard Gratacos
- Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona; and Center for Biomedical Research on Rare Diseases, Madrid, Spain
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37
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Can Placental Histopathology Lesions Predict Recurrence of Small for Gestational Age Neonates? Reprod Sci 2018; 25:1485-1491. [DOI: 10.1177/1933719117749757] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Spurway J, Logan P, Pak SC, Nielsen S. Reference ranges for the intra-amniotic umbilical cord vein diameter, peak velocity and blood flow in a regional NSW population. Australas J Ultrasound Med 2017; 20:155-162. [PMID: 34760489 PMCID: PMC8409896 DOI: 10.1002/ajum.12060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AIM To construct gestational age (GA)-related reference ranges of the intra-amniotic umbilical cord vein (UCV) diameter, peak velocity (PV) and blood flow (Qucv) using a Central West New South Wales population. MATERIALS AND METHODS This was a prospective, quasi-experimental study of low risk, singleton pregnancies (n = 321) between 16 and 42 weeks of gestation. Participation was voluntary following informed consent. The UCV diameter and PV were measured using B mode and duplex Doppler respectively, and Qucv calculated. Percentile values and reference range graphs were established using quantile regression modelling in R statistical software. Intraclass correlation coefficients (ICCs) were calculated to assess the intra and intersonographer reliability. RESULTS Reference ranges for the UCV diameter, PV and Qucv were established and graphed. All three UCV measurements increased with advancing GA, with both diameter and Qucv exhibiting a decline in the late third trimester. The intrasonographer and intersonographer ICCs for the UCV diameter and PV showed almost perfect agreement within and between sonographers. CONCLUSION Gestational age-related reference ranges for the UCV diameter, PV and Qucv were developed using quantile regression from a cohort of low risk, singleton pregnancies in Central West NSW. These reference ranges have the potential to assist in the diagnosis and monitoring of fetal growth restriction.
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Affiliation(s)
- Jacqueline Spurway
- Medical Imaging DepartmentOrange Health ServicePO Box 319OrangeNew South Wales2800Australia
| | - Patricia Logan
- School of Biomedical SciencesCharles Sturt UniversityLocked Bag 49DubboNew South Wales2830Australia
| | - Sok Cheon Pak
- School of Biomedical SciencesCharles Sturt UniversityPanorama AvenueBathurstNew South Wales2795Australia
| | - Sharon Nielsen
- Quantitative Consulting UnitCharles Sturt UniversityLocked Bag 588Wagga WaggaNew South Wales2678Australia
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Bligh LN, Alsolai A, Greer RM, Kumar S. Screening for adverse perinatal outcomes: uterine artery Doppler, cerebroplacental ratio and estimated fetal weight in low-risk women at term. J Matern Fetal Neonatal Med 2017; 31:3301-3307. [DOI: 10.1080/14767058.2017.1369518] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Larissa N. Bligh
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, Queensland, Australia
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Mater’s Centre for Maternal Fetal Medicine, Mater Mothers’ Hospitals, Queensland, Australia
| | - Amal Alsolai
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, Queensland, Australia
- College of Applied Medical Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Ristan M. Greer
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - Sailesh Kumar
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Herston, Queensland, Australia
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Mater’s Centre for Maternal Fetal Medicine, Mater Mothers’ Hospitals, Queensland, Australia
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MacDonald TM, Hui L, Tong S, Robinson AJ, Dane KM, Middleton AL, Walker SP. Reduced growth velocity across the third trimester is associated with placental insufficiency in fetuses born at a normal birthweight: a prospective cohort study. BMC Med 2017; 15:164. [PMID: 28854913 PMCID: PMC5577811 DOI: 10.1186/s12916-017-0928-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Accepted: 08/09/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND While being small-for-gestational-age due to placental insufficiency is a major risk factor for stillbirth, 50% of stillbirths occur in appropriate-for-gestational-age (AGA, > 10th centile) fetuses. AGA fetuses are plausibly also at risk of stillbirth if placental insufficiency is present. Such fetuses may be expected to demonstrate declining growth trajectory across pregnancy, although they do not fall below the 10th centile before birth. We investigated whether reduced growth velocity in AGA fetuses is associated with antenatal, intrapartum and neonatal indicators of placental insufficiency. METHODS We performed a prospective cohort study of 308 nulliparous women who subsequently gave birth to AGA infants. Ultrasound was utilised at 28 and 36 weeks' gestation to determine estimated fetal weight (EFW) and abdominal circumference (AC). We correlated relative EFW and AC growth velocities with three clinical indicators of placental insufficiency, namely (1) fetal cerebroplacental ratio (CPR; CPR < 5th centile reflects placental resistance, and blood flow redistribution to the brain - a fetal response to hypoxia); (2) neonatal acidosis after the hypoxic challenge of labour (umbilical artery (UA) pH < 7.15 at birth); and (3) low neonatal body fat percentage (BF%, measured by air displacement plethysmography) reflecting reduced nutritional reserve in utero. RESULTS For each one centile reduction in EFW growth velocity between 28 and 36 weeks' gestation, there was a 2.4% increase in the odds of cerebral redistribution (CPR < 5th centile, odds ratio (OR) (95% confidence interval) = 1.024 (1.005-1.042), P = 0.012) and neonatal acidosis (UA pH < 7.15, OR = 1.024 (1.003-1.046), P = 0.023), and a 3.3% increase in the odds of low BF% (OR = 1.033 (1.001-1.067), P = 0.047). A decline in EFW of > 30 centiles between 28 and 36 weeks (compared to greater relative growth) was associated with cerebral redistribution (CPR < 5th centile relative risk (RR) = 2.80 (1.25-6.25), P = 0.026), and a decline of > 35 centiles was associated with neonatal acidosis (UA pH < 7.15 RR = 3.51 (1.40-8.77), P = 0.030). Similar associations were identified between low AC growth velocity and clinical indicators of placental insufficiency. CONCLUSIONS Reduced growth velocity between 28 and 36 weeks' gestation among fetuses born AGA is associated with antenatal, intrapartum and neonatal indicators of placental insufficiency. These fetuses potentially represent an important unrecognised cohort at increased risk of stillbirth and may warrant more intensive antenatal surveillance.
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Affiliation(s)
- Teresa M MacDonald
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia. .,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia. .,Translational Obstetrics Group, University of Melbourne, Melbourne, Australia. .,Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.
| | - Lisa Hui
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, Australia
| | - Stephen Tong
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, Australia
| | | | - Kirsten M Dane
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | | | - Susan P Walker
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia.,Translational Obstetrics Group, University of Melbourne, Melbourne, Australia
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Suspected Fetal Growth Restriction at 37 Weeks: A Comparison of Doppler and Placental Pathology. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3723879. [PMID: 28409154 PMCID: PMC5376925 DOI: 10.1155/2017/3723879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/04/2017] [Accepted: 03/12/2017] [Indexed: 11/17/2022]
Abstract
Objective. Our objective was determining if abnormal Doppler evaluation had a higher prevalence of placental pathology compared to normal Doppler in suspected fetal growth restriction (FGR) of cases delivered at 37 weeks. Study Design. This retrospective cohort study of suspected FGR singletons with antenatal Doppler evaluation delivered at 37 weeks had a primary outcome of the prevalence of placental pathology related to FGR. Significance was defined as p ≤ 0.05. Results. Of 100 pregnancies 46 and 54 were in the abnormal and normal Doppler cohorts, respectively. Placental pathology was more prevalent with any abnormal Doppler, 84.8% versus 55.6%, odds ratio (OR) 4.46, 95% confidence interval (CI): 1.55, 13.22, and p = 0.002. Abnormal middle cerebral artery (MCA) Doppler had a higher prevalence: 96.2% versus 54.8%, OR 20.7, 95% CI: 2.54, 447.1, and p < 0.001. Conclusion. Abnormal Doppler was associated with more placental pathology in comparison to normal Doppler in fetuses with suspected FGR. Abnormal MCA Doppler had the strongest association.
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Triunfo S, Crispi F, Gratacos E, Figueras F. Prediction of delivery of small-for-gestational-age neonates and adverse perinatal outcome by fetoplacental Doppler at 37 weeks' gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:364-371. [PMID: 27241184 DOI: 10.1002/uog.15979] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 05/05/2016] [Accepted: 05/23/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To explore the predictive capacity of fetoplacental Doppler at 37 weeks' gestation in identifying small-for-gestational-age (SGA) neonates, fetal growth restriction (FGR) and adverse perinatal outcome. METHODS This was a prospective cohort study of low-risk singleton pregnancies undergoing ultrasound assessment at 37 weeks. At study inclusion, biometry for estimated fetal weight (EFW), and fetoplacental Doppler variables (uterine artery pulsatility index (UtA-PI), cerebroplacental ratio (CPR) and umbilical vein blood flow (UVBF) normalized by EFW) were measured. SGA was defined as a customized birth weight between the 3rd and 10th centiles, and FGR was defined as a birth weight < 3rd centile, according to local standards. Adverse perinatal outcomes included emergency Cesarean section for non-reassuring fetal status, 5-min Apgar score < 7 and neonatal acidosis at birth. RESULTS A total of 946 pregnancies were included in the study. Of these, 89 (9.4%) were classified as SGA and 40 (4.2%) as FGR, with an overall rate of adverse perinatal outcome of 4.9%. At a fixed 10% false-positive rate (FPR), the detection rate of SGA by EFW, UtA-PI, CPR, UVBF and by a combination of Doppler variables (UtA-PI and CPR) and EFW was 59.2%, 10.5%, 13.7%, 3.2% and 61.0%, respectively. At a fixed 10% FPR, the detection rate of FGR by EFW, UtA-PI, CPR, UVBF and a combination of CPR and EFW centile was 83.3%, 13.9%, 27.8%, 13.9% and 88.6%, respectively. At a fixed 10% FPR, the detection rate of adverse perinatal outcome by EFW, UtA-PI, CPR and UVBF was 19.2%, 9.2%, 23.1% and 16.9%, respectively, while combining EFW with Doppler variables (including CPR and UVBF normalized by EFW) improved the detection rate to nearly 30%. CONCLUSION In low-risk pregnancies, Doppler evaluation at 37 weeks' gestation did not improve the prediction of SGA and FGR compared with that given by EFW alone, however, combining Doppler variables with EFW improved the prediction of adverse perinatal outcomes given by these parameters alone, although not markedly. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- S Triunfo
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Crispi
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - E Gratacos
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - F Figueras
- Fetal i + D Fetal Medicine Research Center, BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Center for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Gudmundsson S, Flo K, Ghosh G, Wilsgaard T, Acharya G. Placental pulsatility index: a new, more sensitive parameter for predicting adverse outcome in pregnancies suspected of fetal growth restriction. Acta Obstet Gynecol Scand 2017; 96:216-222. [DOI: 10.1111/aogs.13060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 11/12/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Saemundur Gudmundsson
- Department of Obstetrics and Gynecology; Skane University Hospital; University of Lund; Malmö Sweden
| | - Kari Flo
- Women's Health and Perinatology Research Group; Department of Clinical Medicine; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Obstetrics and Gynecology; University Hospital of North Norway; Tromsø Norway
| | - Gisela Ghosh
- Department of Obstetrics and Gynecology; Skane University Hospital; University of Lund; Malmö Sweden
| | - Tom Wilsgaard
- Department of Community Medicine; Faculty of Health Sciences; UiT - The Arctic University of Norway; Tromsø Norway
| | - Ganesh Acharya
- Women's Health and Perinatology Research Group; Department of Clinical Medicine; Faculty of Health Sciences; University of Tromsø; Tromsø Norway
- Department of Obstetrics and Gynecology; University Hospital of North Norway; Tromsø Norway
- Department of Clinical Science, Intervention and Technology; Karolinska Institute; Stockholm Sweden
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Dall’Asta A, Brunelli V, Prefumo F, Frusca T, Lees CC. Early onset fetal growth restriction. Matern Health Neonatol Perinatol 2017; 3:2. [PMID: 28116113 PMCID: PMC5241928 DOI: 10.1186/s40748-016-0041-x] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/27/2016] [Indexed: 01/01/2023] Open
Abstract
Fetal growth restriction (FGR) diagnosed before 32 weeks is identified by fetal smallness associated with Doppler abnormalities and is associated with significant perinatal morbidity and mortality and maternal complications. Recent studies have provided new insights into pathophysiology, management options and postnatal outcomes of FGR. In this paper we review the available evidence regarding diagnosis, management and prognosis of fetuses diagnosed with FGR before 32 weeks of gestation.
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Affiliation(s)
- Andrea Dall’Asta
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Valentina Brunelli
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine Unit, University of Brescia, Brescia, Italy
| | - Tiziana Frusca
- Department of Obstetrics & Gynecology, University of Parma, Parma, Italy
| | - Christoph C Lees
- Centre for Fetal Care, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS United Kingdom
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Department of Development and Regeneration, KU Leuven, Belgium
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Aljunaidy MM, Morton JS, Cooke CL, Davidge ST. Maternal vascular responses to hypoxia in a rat model of intrauterine growth restriction. Am J Physiol Regul Integr Comp Physiol 2016; 311:R1068-R1075. [PMID: 27760732 DOI: 10.1152/ajpregu.00119.2016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 10/06/2016] [Accepted: 10/12/2016] [Indexed: 11/22/2022]
Abstract
Intrauterine growth restriction (IUGR) is a common pregnancy complication and is a leading cause of fetal morbidity and mortality. Placental hypoxia contributes to adverse fetal consequences, such as IUGR. Exposing pregnant rats to hypoxia can lead to IUGR; however, assessment of maternal vascular function in a rat model of hypoxia, and the mechanisms that may contribute to adverse pregnancy outcomes, has not been extensively studied. We hypothesized that exposing pregnant rats to hypoxia will affect maternal systemic vascular function and increase the uterine artery resistance index (RI), which will be associated with IUGR. To test this hypothesis, pregnant rats were kept in normoxia (21% O2) or hypoxia (11% O2) from gestational day (GD) 6 to 20 Maternal blood pressure, uteroplacental resistance index (RI) (ultrasound biomicroscopy), and vascular function (wire myography) were assessed in uterine and mesenteric arteries. Fetal weight was significantly reduced (P < 0.001), while maternal blood pressure was increased (P < 0.05) in rats exposed to hypoxia. Maternal vascular function was also affected after exposure to hypoxia, including impaired endothelium-dependent vasodilation responses to methacholine in isolated uterine arteries (pEC50 normoxia: 6.55 ± 0.23 vs. hypoxia: 5.02 ± 0.35, P < 0.01) and a reduced uterine artery RI in vivo (normoxia: 0.63 ± 0.04 vs. hypoxia: 0.53 ± 0.01, P < 0.05); associated with an increase in umbilical vein RI (normoxia: 0.35 ± 0.02 vs. hypoxia: 0.45 ± 0.04, P < 0.05). These data demonstrate maternal and fetal alterations in vascular function due to prenatal exposure to hypoxia. Further, although there was a compensatory reduction in uterine artery RI in the hypoxia groups, this was not sufficient to prevent IUGR.
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Affiliation(s)
- Mais M Aljunaidy
- Department of Obstetrics and Gynecology, University of Alberta, Alberta, Edmonton, Canada.,Department of Physiology, University of Alberta, Alberta, Edmonton, Canada; and.,Women and Children's Health Research Institute and the Cardiovascular Research Centre, Edmonton, Alberta, Canada
| | - Jude S Morton
- Department of Obstetrics and Gynecology, University of Alberta, Alberta, Edmonton, Canada.,Women and Children's Health Research Institute and the Cardiovascular Research Centre, Edmonton, Alberta, Canada
| | - Christy-Lynn Cooke
- Department of Obstetrics and Gynecology, University of Alberta, Alberta, Edmonton, Canada.,Women and Children's Health Research Institute and the Cardiovascular Research Centre, Edmonton, Alberta, Canada
| | - Sandra T Davidge
- Department of Obstetrics and Gynecology, University of Alberta, Alberta, Edmonton, Canada; .,Department of Physiology, University of Alberta, Alberta, Edmonton, Canada; and.,Women and Children's Health Research Institute and the Cardiovascular Research Centre, Edmonton, Alberta, Canada
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Abulé RMD, Bernardes LS, Doro GF, Miyadahira S, Francisco RPV. Reduced placental volume and flow in severe growth restricted fetuses. Clinics (Sao Paulo) 2016; 71:332-7. [PMID: 27438567 PMCID: PMC4930658 DOI: 10.6061/clinics/2016(06)08] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Accepted: 03/21/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To evaluate placental volume and vascular indices in pregnancies with severe fetal growth restriction and determine their correlations to normal reference ranges and Doppler velocimetry results of uterine and umbilical arteries. METHODS Twenty-seven fetuses with estimated weights below the 3rd percentile for gestational age were evaluated. Placental volume and vascular indices, including vascularization, flow, and vascularization flow indices, were measured by three-dimensional ultrasound using a rotational technique and compared to a previously described nomogram. The observed-to-expected placental volume ratio for gestational age and observed-to-expected placental volume ratio for fetal weight were calculated. Placental parameters correlated with the Doppler velocimetry results of uterine and umbilical arteries. RESULTS The mean uterine artery pulsatility index was negatively correlated with the observed-to-expected placental volume ratio for gestational age, vascularization index and vascularization flow index. The observed-to-expected placental volume ratio for gestational age and observed-to-expected placental volume ratio for fetal weight and vascularization index were significantly lower in the group with a bilateral protodiastolic notch. No placental parameter correlated with the umbilical artery pulsatility index. CONCLUSIONS Pregnancies complicated by severe fetal growth restriction are associated with reduced placental volume and vascularization. These findings are related to changes in uterine artery Doppler velocimetry. Future studies on managing severe fetal growth restriction should focus on combined results of placental three-dimensional ultrasound and Doppler studies of uterine arteries.
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Affiliation(s)
- Renata Montes Dourado Abulé
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, Disciplina de Obstetrícia, São Paulo/SP, Brazil
| | - Lisandra Stein Bernardes
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, Disciplina de Obstetrícia, São Paulo/SP, Brazil
- E-mail:
| | - Giovana Farina Doro
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, Disciplina de Obstetrícia, São Paulo/SP, Brazil
| | - Seizo Miyadahira
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, Disciplina de Obstetrícia, São Paulo/SP, Brazil
| | - Rossana Pulcinelli Vieira Francisco
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Obstetrícia e Ginecologia, Disciplina de Obstetrícia, São Paulo/SP, Brazil
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Briana DD, Boutsikou M, Boutsikou T, Dodopoulos T, Gourgiotis D, Malamitsi-Puchner A. Plasma copeptin may not be a sensitive marker of perinatal stress in healthy full-term growth-restricted fetuses. J Matern Fetal Neonatal Med 2016; 30:705-709. [DOI: 10.1080/14767058.2016.1183632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Despina D. Briana
- Department of Neonatology, National and Kapodistrian University of Athens, Athens, Greece and
| | - Maria Boutsikou
- Department of Neonatology, National and Kapodistrian University of Athens, Athens, Greece and
| | - Theodora Boutsikou
- Department of Neonatology, National and Kapodistrian University of Athens, Athens, Greece and
| | - Thanasis Dodopoulos
- Laboratory of Clinical Biochemistry-Molecular Diagnostics, 2nd Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Gourgiotis
- Laboratory of Clinical Biochemistry-Molecular Diagnostics, 2nd Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
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Korzeniewski SJ, Romero R, Chaiworapongsa T, Chaemsaithong P, Kim CJ, Kim YM, Kim JS, Yoon BH, Hassan SS, Yeo L. Maternal plasma angiogenic index-1 (placental growth factor/soluble vascular endothelial growth factor receptor-1) is a biomarker for the burden of placental lesions consistent with uteroplacental underperfusion: a longitudinal case-cohort study. Am J Obstet Gynecol 2016; 214:629.e1-629.e17. [PMID: 26688491 DOI: 10.1016/j.ajog.2015.11.015] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 09/21/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Placental lesions consistent with maternal vascular underperfusion (MVU) are thought to be pathogenically linked to preeclampsia, small-for-gestational-age newborns, fetal death, and spontaneous preterm labor and delivery; yet, these lesions cannot be diagnosed antenatally. We previously reported that patients with such conditions and lesions have an abnormal profile of the angiogenic placental growth factor (PlGF) and antiangiogenic factors (eg, soluble vascular endothelial growth factor receptor [sVEGFR]-1). OBJECTIVE The objectives of this study were to: (1) examine the relationship between the maternal plasma PlGF/sVEGFR-1 concentration ratio (referred to herein as angiogenic index-1) and the burden of histologic placental features consistent with MVU; and (2) test the hypothesis that angiogenic index-1 can identify patients in the midtrimester who are destined to deliver before 34 weeks of gestation with multiple (ie, ≥3) histologic placental features consistent with MVU. STUDY DESIGN A 2-stage case-cohort sampling strategy was used to select participants from among 4006 women with singleton gestations enrolled from 2006 through 2010 in a longitudinal study. Maternal plasma angiogenic index-1 ratios were determined using enzyme-linked immunosorbent assays. Placentas underwent histologic examination according to standardized protocols by experienced pediatric pathologists who were blinded to clinical diagnoses and pregnancy outcomes. The diagnosis of lesions consistent with MVU was made using criteria proposed by the Perinatal Section of the Society for Pediatric Pathology. Weighted analyses were performed to reflect the parent cohort; "n*" is used to reflect weighted frequencies. RESULTS (1) Angiogenic index-1 (PlGF/sVEGFR-1) concentration ratios were determined in 7560 plasma samples collected from 1499 study participants; (2) the prevalence of lesions consistent with MVU was 21% (n* = 833.9/3904) and 27% (n* = 11.4/42.7) of women with ≥3 MVU lesions delivered before 34 weeks of gestation; (3) a low angiogenic index-1 (<2.5th quantile for gestational age) in maternal plasma samples obtained within 48 hours of delivery had a sensitivity of 73% (n* = 8.3/11.4; 95% confidence interval [CI], 47-98%), a specificity of 94% (n* = 3130.9/3316.2; 95% CI, 94-95%), a positive likelihood ratio of 12.2, and a negative likelihood ratio of 0.29 in the identification of patients who delivered placentas with ≥3 MVU lesions at <34 weeks; (4) prospectively, at 20-23 weeks of gestation, a maternal plasma concentration of angiogenic index-1 <2.5th quantile identified 70% (n* = 7.2/10.3; 95% CI, 42-98%) of patients who delivered placentas with ≥3 MVU lesions before 34 weeks (specificity, 97% [n* = 2831.3/2918; 95% CI, 96-98%]; positive likelihood ratio, 23; negative likelihood ratio, 0.31); and (5) among women without obstetrical complications who delivered at term, angiogenic index-1 was lower in women with than without placental lesions consistent with MVU (P < .05). CONCLUSION Maternal plasma angiogenic index-1 (PlGF/sVEGFR-1) is the first biomarker for the burden of placental lesions consistent with MVU. We propose that an accumulation of these lesions in placentas delivered before 34 weeks is a histologic counterpart of an antiangiogenic profile.
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Simeone S, Marchi L, Canarutto R, Pina Rambaldi M, Serena C, Servienti C, Mecacci F. Doppler velocimetry and adverse outcome in labor induction for late IUGR. J Matern Fetal Neonatal Med 2016; 30:323-328. [DOI: 10.3109/14767058.2016.1171839] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Serena Simeone
- High Risk Pregnancy Unit, Careggi University Hospital,– Florence, Italy and
| | - Laura Marchi
- Fetal Medicine Unit, Careggi University Hospital,– Florence, Italy
| | - Rita Canarutto
- High Risk Pregnancy Unit, Careggi University Hospital,– Florence, Italy and
| | | | - Caterina Serena
- High Risk Pregnancy Unit, Careggi University Hospital,– Florence, Italy and
| | - Cristina Servienti
- High Risk Pregnancy Unit, Careggi University Hospital,– Florence, Italy and
| | - Federico Mecacci
- High Risk Pregnancy Unit, Careggi University Hospital,– Florence, Italy and
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The hemodynamics of late-onset intrauterine growth restriction by MRI. Am J Obstet Gynecol 2016; 214:367.e1-367.e17. [PMID: 26475425 DOI: 10.1016/j.ajog.2015.10.004] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/24/2015] [Accepted: 10/06/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Late-onset intrauterine growth restriction (IUGR) results from a failure of the placenta to supply adequate nutrients and oxygen to the rapidly growing late-gestation fetus. Limitations in current monitoring methods present the need for additional techniques for more accurate diagnosis of IUGR in utero. New magnetic resonance imaging (MRI) technology now provides a noninvasive technique for fetal hemodynamic assessment, which could provide additional information over conventional Doppler methods. OBJECTIVE The objective of the study was to use new MRI techniques to measure hemodynamic parameters and brain growth in late-onset IUGR fetuses. STUDY DESIGN This was a prospective observational case control study to compare the flow and T2 of blood in the major fetal vessels and brain imaging findings using MRI. Indexed fetal oxygen delivery and consumption were calculated. Middle cerebral artery and umbilical artery pulsatility indexes and cerebroplacental ratio were acquired using ultrasound. A score of ≥ 2 of the 4 following parameters defined IUGR: (1) birthweight the third centile or less or 20% or greater drop in the centile in estimated fetal weight; (2) lowest cerebroplacental ratio after 30 weeks less than the fifth centile; (3) ponderal index < 2.2; and (4) placental histology meets predefined criteria for placental underperfusion. Measurements were compared between the 2 groups (Student t test) and correlations between parameters were analyzed (Pearson's correlation). MRI measurements were compared with Doppler parameters for identifying IUGR defined by postnatal criteria (birthweight, placental histology, ponderal index) using receiver-operating characteristic curves. RESULTS We studied 14 IUGR and 26 non-IUGR fetuses at 35 weeks' gestation. IUGR fetuses had lower umbilical vein (P = .004) and pulmonary blood flow (P = .01) and higher superior vena caval flow (P < .0001) by MRI. IUGR fetuses had asymmetric growth but smaller brains than normal fetuses (P < .0001). Newborns with IUGR also had smaller brains with otherwise essentially normal findings on MRI. Vessel T2s, oxygen delivery, oxygen consumption, middle cerebral artery pulsatility index, and cerebroplacental ratio were all significantly lower in IUGR fetuses, whereas there was no significant difference in umbilical artery pulsatility index. IUGR score correlated positively with superior vena caval flow and inversely with oxygen delivery, oxygen consumption, umbilical vein T2, and cerebroplacental ratio. Receiver-operating characteristic curves revealed equivalent performance of MRI and Doppler techniques in identifying IUGR that was defined based on postnatal parameters with superior vena caval flow area under the curve of 0.94 (95% confidence interval, 0.87-1.00) vs a cerebroplacental ratio area under the curve of 0.80 (95% confidence interval, 0.64-0.97). CONCLUSION MRI revealed the expected circulatory redistribution in response to hypoxia in IUGR fetuses. The reduced oxygen delivery in IUGR fetuses indicated impaired placental oxygen transport, whereas reduced oxygen consumption presumably reflected metabolic adaptation to diminished substrate delivery, resulting in slower fetal growth. Despite brain sparing, placental insufficiency limits fetal brain growth. Superior vena caval flow and umbilical vein T2 by MRI may be useful new markers of late-onset IUGR.
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