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Vasapollo B, Zullino S, Novelli GP, Farsetti D, Ottanelli S, Clemenza S, Micaglio M, Ferrazzi E, Di Martino DD, Ghi T, Di Pasquo E, Orabona R, Corbella P, Frigo MG, Prefumo F, Stampalija T, Giannubilo SR, Valensise H, Mecacci F. Maternal Hemodynamics from Preconception to Delivery: Research and Potential Diagnostic and Therapeutic Implications: Position Statement by Italian Association of Pre-Eclampsia and Italian Society of Perinatal Medicine. Am J Perinatol 2024. [PMID: 38350640 DOI: 10.1055/a-2267-3994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
OBJECTIVE The Italian Association of Preeclampsia (AIPE) and the Italian Society of Perinatal Medicine (SIMP) developed clinical questions on maternal hemodynamics state of the art. STUDY DESIGN AIPE and SIMP experts were divided in small groups and were invited to propose an overview of the existing literature on specific topics related to the clinical questions proposed, developing, wherever possible, clinical and/or research recommendations based on available evidence, expert opinion, and clinical importance. Draft recommendations with a clinical rationale were submitted to 8th AIPE and SIMP Consensus Expert Panel for consideration and approval, with at least 75% agreement required for individual recommendations to be included in the final version. RESULTS More and more evidence in literature underlines the relationship between maternal and fetal hemodynamics, as well as the relationship between maternal cardiovascular profile and fetal-maternal adverse outcomes such as fetal growth restriction and hypertensive disorders of pregnancy. Experts agreed on proposing a classification of pregnancy hypertension, complications, and cardiovascular states based on three different hemodynamic profiles depending on total peripheral vascular resistance values: hypodynamic (>1,300 dynes·s·cm-5), normo-dynamic, and hyperdynamic (<800 dynes·s·cm-5) circulation. This differentiation implies different therapeutical strategies, based drugs' characteristics, and maternal cardiovascular profile. Finally, the cardiovascular characteristics of the women may be useful for a rational approach to an appropriate follow-up, due to the increased cardiovascular risk later in life. CONCLUSION Although the evidence might not be conclusive, given the lack of large randomized trials, maternal hemodynamics might have great importance in helping clinicians in understanding the pathophysiology and chose a rational treatment of patients with or at risk for pregnancy complications. KEY POINTS · Altered maternal hemodynamics is associated to fetal growth restriction.. · Altered maternal hemodynamics is associated to complicated hypertensive disorders of pregnancy.. · Maternal hemodynamics might help choosing a rational treatment during hypertensive disorders..
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Affiliation(s)
- Barbara Vasapollo
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Gian Paolo Novelli
- Department of Integrated Care Services, Prehospitalization Unit, Policlinico di Tor Vergata, Rome, Italy
| | - Daniele Farsetti
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Serena Ottanelli
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Sara Clemenza
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Unit of Obstetric and Gynecologic Anesthesia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Tullio Ghi
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elvira Di Pasquo
- Obstetrics and Gynecology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Rossana Orabona
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paola Corbella
- Maternal Infant Department SC, Obstetrics and Gynecology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Grazia Frigo
- Department of Anesthesia and Resuscitation in Obstetrics, San Giovanni Calibita Fatebenefratelli Hospital, Rome, Italy
| | - Federico Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, Genova, 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
| | - Stefano Raffaele Giannubilo
- Department of Obstetrics and Gynecology, Marche Polytechnic University, Ancona, Italy
- Department of Clinical Sciences, Polytechnic University of Marche Salesi Hospital, Ancona, Italy
| | - Herbert Valensise
- Department of Surgical Sciences, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino, Rome, Italy
| | - Federico Mecacci
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
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Di Martino DD, Stampalija T, Zullino S, Fusè F, Garbin M, Parasiliti M, Sterpi V, Farina A, Ferrazzi E. Maternal hemodynamic profile during pregnancy and in the post-partum in hypertensive disorders of pregnancy and fetal growth restriction. Am J Obstet Gynecol MFM 2023; 5:100841. [PMID: 36563878 DOI: 10.1016/j.ajogmf.2022.100841] [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: 11/17/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Maternal cardiovascular changes, occurring since the beginning of pregnancy, are necessary for normal placentation and regular evolution of pregnancy. OBJECTIVE This study aimed to compare the hemodynamic profiles and cardiac remodeling of women with hypertensive disorders of pregnancy and either appropriate for gestational age fetuses or growth-restricted fetuses, women with normotensive pregnancies complicated by fetal growth restriction, and women with uncomplicated pregnancies, during pregnancy and the postpartum period. STUDY DESIGN A prospective longitudinal case-control design was used for this study. Over the study period, 220 eligible women with singleton pregnancies were selected for the analysis and divided into 4 groups: (1) hypertensive disorders of pregnancy with appropriate for gestational age fetuses; (2) hypertensive disorders of pregnancy with fetal growth restriction; (3) normotensive fetal growth restriction; and (4) controls. Ultrasound fetal biometry and fetoplacental Doppler velocimetry were performed at recruitment. Maternal hemodynamic assessment using transthoracic echocardiography was performed at the time of recruitment by a dedicated cardiologist blinded to maternal clinical data. The same assessments were performed in 104 patients at 32 weeks (interquartile range, 24-40) after delivery by the same cardiologist. RESULTS During pregnancy, women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction group showed significantly lower cardiac output and increased compared with those in the control group. These values were associated with concentric remodeling of the left ventricle owing to relatively increased wall thickness, which was not accompanied by an increase in left ventricular mass. Isolated fetal growth restriction presented similar but less important hemodynamic changes; however, there was no change in relative wall thickness. At postpartum follow-up, the hemodynamic parameters of women in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and isolated-fetal-growth-restriction groups reverted to values similar to those of the control group. Only 8.3% of women in these groups experienced hypertension even in the postpartum period, and asymptomatic stage-B cardiac failure was observed for 17% at echocardiography. In the group of women with hypertensive disorders of pregnancy and appropriate for gestational age fetuses, cardiac output increased as in normal pregnancies, but total vascular resistance was significantly higher; hypertension then occurred, along with ventricular concentric hypertrophy and diastolic dysfunction. At postpartum follow-up, women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed significantly higher mean arterial pressure, total vascular resistance, and left ventricular mass compared with those in the control group. Persistent hypertension and asymptomatic stage-B cardiac failure were observed in 39.1% and 13% of women in the former group, respectively. CONCLUSION Pregnancies with hypertensive disorders of pregnancy and fetal growth restriction and normotensive pregnancies with fetal growth restriction were associated with the hemodynamic profile of lower heart rate and cardiac output, most likely because of abnormal adaptation to pregnancy, as confirmed by abnormal changes from pregnancy to the postpartum period. The heart rates and cardiac output of women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group showed changes opposite to those observed in the hypertensive-disorders-of-pregnancy-fetal-growth-restriction and fetal-growth-restriction groups. Obesity and other metabolic risk factors, significantly prevalent in women in the hypertensive-disorders-of-pregnancy-appropriate-for-gestational-age-fetus group, predispose to hypertension and cardiovascular diseases during pregnancy and the postpartum period, potentially offering a window for personalized prevention. Such preventive strategies could differ in women with hypertensive disorders of pregnancy and fetal growth restriction characterized by poor early placental development.
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Affiliation(s)
- Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy (Dr Stampalija); Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy (Dr Stampalija)
| | - Sara Zullino
- Division of Obstetrics and Gynecology, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Dr Zullino).
| | - Federica Fusè
- Department of Obstetrics and Gynecology, University of Milan, Hospital Luigi Sacco, Milan, Italy (Dr Fusè)
| | - Massimo Garbin
- Unit of Cardiology, Vittore Buzzi Children's Hospital, Milan, Italy (Dr Garbin)
| | - Marco Parasiliti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Vittoria Sterpi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi)
| | - Antonio Farina
- Division of Obstetrics and Prenatal Medicine, Department of Medicine and Surgery, IRCCS Sant'Orsola-Malpighi Polyclinic, University of Bologna, Bologna, Italy (Dr Farina)
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy (Drs Di Martino, Parasiliti, Sterpi, and Ferrazzi); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (Dr Ferrazzi)
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Fantasia I, Zamagni G, Lees C, Mylrea‐Foley B, Monasta L, Mullins E, Prefumo F, Stampalija T. Current practice in the diagnosis and management of fetal growth restriction: An international survey. Acta Obstet Gynecol Scand 2022; 101:1431-1439. [PMID: 36214456 PMCID: PMC9812103 DOI: 10.1111/aogs.14466] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/08/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The aim of this survey was to evaluate the current practice in respect of diagnosis and management of fetal growth restriction among obstetricians in different countries. MATERIAL AND METHODS An e-questionnaire was sent via REDCap with "click thru" links in emails and newsletters to obstetric practitioners in different countries and settings with different levels of expertise. Clinical scenarios in early and late fetal growth restriction were given, followed by structured questions/response pairings. RESULTS A total of 275 participants replied to the survey with 87% of responses complete. Participants were obstetrician/gynecologists (54%; 148/275) and fetal medicine specialists (43%; 117/275), and the majority practiced in a tertiary teaching hospital (56%; 153/275). Delphi consensus criteria for fetal growth restriction diagnosis were used by 81% of participants (223/275) and 82% (225/274) included a drop in fetal growth velocity in their diagnostic criteria for late fetal growth restriction. For early fetal growth restriction, TRUFFLE criteria were used for fetal monitoring and delivery timing by 81% (223/275). For late fetal growth restriction, indices of cerebral blood flow redistribution were used by 99% (250/252), most commonly cerebroplacental ratio (54%, 134/250). Delivery timing was informed by cerebral blood flow redistribution in 72% (176/244), used from ≥32 weeks of gestation. Maternal biomarkers and hemodynamics, as additional tools in the context of early-onset fetal growth restriction (≤32 weeks of gestation), were used by 22% (51/232) and 46% (106/230), respectively. CONCLUSIONS The diagnosis and management of fetal growth restriction are fairly homogeneous among different countries and levels of practice, particularly for early fetal growth restriction. Indices of cerebral flow distribution are widely used in the diagnosis and management of late fetal growth restriction, whereas maternal biomarkers and hemodynamics are less frequently assessed but more so in early rather than late fetal growth restriction. Further standardization is needed for the definition of cerebral blood flow redistribution.
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Affiliation(s)
- Ilaria Fantasia
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health—IRCCS “Burlo Garofolo”TriesteItaly
| | - Giulia Zamagni
- Clinical Epidemiology and Public Health Research UnitInstitute for Maternal and Child Health—IRCCS "Burlo Garofolo"TriesteItaly
| | - Christoph Lees
- Imperial College London, Obstetrics and GynecologyQueen Charlotte's & Chelsea Hospital LondonLondonUK
| | - Bronacha Mylrea‐Foley
- Imperial College London, Obstetrics and GynecologyQueen Charlotte's & Chelsea Hospital LondonLondonUK
| | - Lorenzo Monasta
- Clinical Epidemiology and Public Health Research UnitInstitute for Maternal and Child Health—IRCCS "Burlo Garofolo"TriesteItaly
| | - Edward Mullins
- Imperial College London, Obstetrics and GynecologyQueen Charlotte's & Chelsea Hospital LondonLondonUK
| | - Federico Prefumo
- Obstetrics and Gynecology UnitIRCCS Giannina Gaslini InstituteGenoaItaly
| | - Tamara Stampalija
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health—IRCCS “Burlo Garofolo”TriesteItaly,Department of Medical, Surgical and Health SciencesUniversity of TriesteTriesteItaly
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Fetal and Neonatal Middle Cerebral Artery Hemodynamic Changes and Significance under Ultrasound Detection in Hypertensive Disorder Complicating Pregnancy Patients with Different Severities. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6110228. [PMID: 35799667 PMCID: PMC9256346 DOI: 10.1155/2022/6110228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 11/18/2022]
Abstract
Colour Doppler ultrasound was applied for monitoring the hemodynamic parameters of fetal uterine artery (UtA), umbilical artery (UA), and middle cerebral artery (MCA) during pregnancy. In hypertension disease complicating pregnancy, these hemodynamic measures and their therapeutic applicability value were reviewed (HDCP). 120 singleton pregnant women were chosen, with 40 cases of mild preeclampsia (mild group), 40 cases of severe preeclampsia (severe group), and 40 normal control pregnant women (control group). The hemodynamic parameters of UtA, MCA, and UA were monitored in the three groups, including pulsatility index (PI), resistance index (RI), and the systolic/diastolic velocity (S/D). The parameters PI, RI, S/D, and venous catheter shunt rate (Qdv/Quv) of UtA and UA in the severe group were higher than those in the normal group and the mild group, showing the differences statistically significant (
). The PI, RI, and S/D of MCA in the severe group were lower than those in the normal group and the mild group (
). The changing trends of PI, RI, and S/D in the severe group were all first increased and then decreased in the early, middle, and later pregnancy (
). The area under the curve (AUC) was 0.98 in the receiver operating characteristic (ROC) curve created using a combination of hemodynamic measures and pregnancy outcomes, and the sensitivity and specificity for predicting bad outcomes were 94.7 percent and 96.4 percent, respectively. Colour Doppler ultrasound may accurately detect changes in the PI, RI, and S/D of UtA, MCA, and UA in pregnant women and serve as a reference for determining the intrauterine state of the fetuses and predicting bad pregnancy outcomes. In particular, the parameters in later pregnancy were higher worthy of diagnostic value for adverse pregnancy outcomes. The combination of various parameters could make an improvement of the diagnostic accuracy and provide a basis for guiding treatment as well as determining the optimal timing of delivery.
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Gyselaers W, Lees C. Maternal Low Volume Circulation Relates to Normotensive and Preeclamptic Fetal Growth Restriction. Front Med (Lausanne) 2022; 9:902634. [PMID: 35755049 PMCID: PMC9218216 DOI: 10.3389/fmed.2022.902634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/04/2022] [Indexed: 11/13/2022] Open
Abstract
This narrative review summarizes current evidence on the association between maternal low volume circulation and poor fetal growth. Though much work has been devoted to the study of cardiac output and peripheral vascular resistance, a low intravascular volume may explain why high vascular resistance causes hypertension in women with preeclampsia (PE) that is associated with fetal growth restriction (FGR) and, at the same time, presents with normotension in FGR itself. Normotensive women with small for gestational age babies show normal gestational blood volume expansion superimposed upon a constitutionally low intravascular volume. Early onset preeclampsia (EPE; occurring before 32 weeks) is commonly associated with FGR, and poor plasma volume expandability may already be present before conception, thus preceding gestational volume expansion. Experimentally induced low plasma volume in rodents predisposes to poor fetal growth and interventions that enhance plasma volume expansion in FGR have shown beneficial effects on intrauterine fetal condition, prolongation of gestation and birth weight. This review makes the case for elevating the maternal intravascular volume with physical exercise with or without Nitric Oxide Donors in FGR and EPE, and evaluating its role as a potential target for prevention and/or management of these conditions.
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Affiliation(s)
- Wilfried Gyselaers
- Department of Obstetrics, Ziekenhuis Oost Limburg, Genk, Belgium.,Department of Physiology, Hasselt University, Hasselt, Belgium
| | - Christoph Lees
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom.,Department of Metabolism, Digestion and Reproduction, Institute for Reproductive and Developmental Biology, Imperial College London, London, United Kingdom.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, London, United Kingdom
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Ornaghi S, Caricati A, Di Martino DD, Mossa M, Di Nicola S, Invernizzi F, Zullino S, Clemenza S, Barbati V, Tinè G, Mecacci F, Ferrazzi E, Vergani P. Non-invasive Maternal Hemodynamic Assessment to Classify High-Risk Pregnancies Complicated by Fetal Growth Restriction. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:851971. [PMID: 36992751 PMCID: PMC10012115 DOI: 10.3389/fcdhc.2022.851971] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/23/2022] [Indexed: 11/13/2022]
Abstract
ObjectivesTo verify whether the use of the temporal criterion of 32 weeks’ gestation is effective in identifying maternal hemodynamic differences between early- and late-onset fetal growth restriction (FGR), and to test the statistical performance of a classificatory algorithm for FGR.Materials and methodsA prospective multicenter study conducted at three centers over 17 months. Singleton pregnant women with a diagnosis of FGR based on the international Delphi survey consensus at ≥ 20 weeks of gestation were included. FGR was classified as early-onset if diagnosed <32 weeks’ gestation and as late-onset if ≥32 weeks. Hemodynamic assessment was performed by USCOM-1A at the time of FGR diagnosis. Comparisons between early- and late-onset FGR among the entire study cohort, FGR associated with hypertensive disorders of pregnancy (HDP-FGR), and isolated FGR (i-FGR) were performed. In addition, HDP-FGR cases were compared to i-FGR, regardless of the temporal cut-off of 32 weeks’ gestation. Finally, a classificatory analysis based on the Random Forest model was performed to identify significant variables with the ability to differentiate FGR phenotypes.ResultsDuring the study period, 146 pregnant women fulfilled the inclusion criteria. In 44 cases, FGR was not confirmed at birth, thus limiting the final study population to 102 patients. In 49 (48.1%) women, FGR was associated to HDP. Fifty-nine (57.8%) cases were classified as early-onset. Comparison of the maternal hemodynamics between early- and late-onset FGR did not show any difference. Similarly, non-significant findings were observed in sensitivity analyses performed for HDP-FGR and for i-FGR. In turn, comparison between pregnant women with FGR and hypertension and women with i-FGR, independently of the gestational age at FGR diagnosis, revealed substantial differences, with the former showing higher vascular peripheral resistances and lower cardiac output, among other significant parameters. The classificatory analysis identified both phenotypic and hemodynamic variables as relevant in distinguishing HDP-FGR from i-FGR (p=0.009).ConclusionsOur data show that HDP, rather than gestational age at FGR diagnosis, allows to appreciate specific maternal hemodynamic patterns and to accurately distinguish two different FGR phenotypes. In addition, maternal hemodynamics, alongside phenotypic characteristics, play a central role in classifying these high-risk pregnancies.
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Affiliation(s)
- Sara Ornaghi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
- *Correspondence: Sara Ornaghi,
| | - Andrea Caricati
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Denis Di Martino
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Mossa
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Di Nicola
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Francesca Invernizzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Sara Clemenza
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Valentina Barbati
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
| | - Gabriele Tinè
- Department of Economics and Quantitative Methods, University of Milan-Bicocca, Monza, Italy
| | - Federico Mecacci
- Department of Obstetrics and Gynecology, Biomedical, Experimental and Clinical Sciences, University Hospital Careggi, Florence, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Department of Woman, Child, and Newborn, Fondazione IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical and Community Sciences, University of Milan, Milan, Italy
| | - Patrizia Vergani
- Department of Obstetrics and Gynecology, Unit of Obstetrics, Monza e Brianza per il Bambino e la sua Mamma Foundation Onlus at San Gerardo Hospital, Monza, Italy
- University of Milan-Bicocca School of Medicine and Surgery, Monza, Italy
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Stampalija T, Quadrifoglio M, Casati D, Zullino S, Maggi V, Di Martino D, Rosti E, Mastroianni C, Signorelli V, Ferrazzi E. First trimester placental volume is reduced in hypertensive disorders of pregnancy associated with small for gestational age fetus. J Matern Fetal Neonatal Med 2021; 34:1304-1311. [PMID: 31232131 DOI: 10.1080/14767058.2019.1636026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Trophoblastic invasion and placental growth are critical for pregnancy outcome. The placental volume can be assessed by 3 D ultrasound using Virtual Organ Computer-aided Analysis (VOCAL). Epidemiological and clinical data suggest that there are two different clinical phenotypes of hypertensive disorders of pregnancy (HDP) that coexist at any gestational age: HDP associated to fetal growth impairment and HDP associated to appropriate for gestational age fetal growth. The aim of this study was to determine whether placental volume in the first trimester of pregnancy differs between women with HDP associated or not to fetal growth impairment and uncomplicated pregnancies. METHODS This is a retrospective cross-sectional study of prospectively recruited data in which maternal characteristics, Doppler velocimetry of uterine arteries, and three-dimensional (3 D) volume of the placenta were collected at 11 + 1 - 13 + 6 gestational weeks. The placental quotient (PQ) was calculated as placental volume/crown rump length. RESULTS In a 2-year period, we prospectively collected first trimester data of 1322 women. For the purposes of this cross-sectional study, 57 women that delivered a SGA fetus, 34 that developed HDP-AGA, and six that developed HDP-SGA, respectively, were included in the study as cases. The control group was made of 117 uncomplicated pregnancies. The PQ was higher in women with uncomplicated pregnancies (PQ median 16.36 cm3/cm) than in all other study groups (PQ in SGA: 13.02 cm3/cm, p < .001; PQ in HDP-AGA: 12.65 cm3/cm, p = .002; and PQ in women with HDP-SGA: 8.33 cm3/cm [IQR 6.50-10.13], p < .001). The lowest PQ was observed in women with HDP-SGA and was significantly lower than PQ in either women with SGA or those with HDP-AGA (p = .02 and p = .04, respectively). The mean uterine artery pulsatility index was the highest in women with HDP-SGA (median 2.30) compared to all other groups (uncomplicated pregnancies 1.48, p < .0001; women with SGA 1.59, p = .001; and women with HDP-AGA 1.75, p = .009). DISCUSSION Our findings suggest that HDP associated with SGA is characterized by impaired placental growth and perfusion as soon as in the first trimester of pregnancy. The role of PQ, isolated or in association with other biophysical parameters, to predict HDP with fetal growth impairment remains to be evaluated.
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Affiliation(s)
- Tamara Stampalija
- Unit of Fetal Medicine and Prenatal Diagnosis, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Mariachiara Quadrifoglio
- Unit of Fetal Medicine and Prenatal Diagnosis, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Daniela Casati
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Sara Zullino
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Valeria Maggi
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Daniela Di Martino
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Eleonora Rosti
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Cristina Mastroianni
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Valentina Signorelli
- Department of Obstetrics and Gynecology, Vittore Buzzi Children's Hospital, Milano, Italy
| | - Enrico Ferrazzi
- Department of Obstetrics and Gynecology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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Di Pasquo E, Ghi T, Dall'Asta A, Angeli L, Ciavarella S, Armano G, Sesenna V, Di Peri A, Frusca T. Hemodynamic findings in normotensive women with small-for-gestational-age and growth-restricted fetuses. Acta Obstet Gynecol Scand 2020; 100:876-883. [PMID: 33084031 DOI: 10.1111/aogs.14026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Fetal growth restriction (FGR) in most instances is a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational-age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome. MATERIAL AND METHODS An observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria, and pregnant women underwent hemodynamic assessment using a cardiac output monitor. A group of women with singleton uncomplicated pregnancies ar ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume, and heart rate were measured and compared among the three groups (controls vs FGR vs SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis. RESULTS A total of 51 women with fetal smallness were assessed at 34.8 ± 2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5 ± 0.8 weeks of gestation. Women with FGR had a lower cardiac output Z-score (respectively, -1.3 ± 1.2 vs -0.4 ± 0.8 vs -0.2 ± 1.0; P < .001) and a higher systemic vascular resistance Z-score (respectively, 1.2 ± 1.2 vs 0.2 ± 1.1 vs -0.02 ± 1.2; P < .001) compared with both SGA and controls, whereas no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of neonatal intensive care unit admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; P = .13), but FGR fetuses had a longer hospitalization compared with SGA fetuses (14.2 ± 17.7 vs 4.5 ± 1.6 days; P = .02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (P = .012) and the birthweight Z-score (P = .007) were independent predictors of the length of neonatal hospitalization. CONCLUSIONS Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization.
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Affiliation(s)
- Elvira Di Pasquo
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Andrea Dall'Asta
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Laura Angeli
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Sara Ciavarella
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Giulia Armano
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Veronica Sesenna
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - Antonio Di Peri
- Department of Neonatology, University of Parma, Parma, Italy
| | - Tiziana Frusca
- Department of Medicine and Surgery, Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
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