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DeVore GR, Polanco B, Lee W, Fowlkes JB, Peek EE, Putra M, Hobbins JC. Maternal rest improves growth in small-for-gestational-age fetuses (<10th percentile). Am J Obstet Gynecol 2025; 232:118.e1-118.e12. [PMID: 38842845 PMCID: PMC11579257 DOI: 10.1016/j.ajog.2024.04.024] [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: 03/31/2023] [Revised: 04/20/2024] [Accepted: 04/22/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Optimal management of fetuses diagnosed as small for gestational age based on an estimated fetal weight of <10th percentile represents a major clinical problem. The standard approach is to increase fetal surveillance with serial biometry and antepartum testing to assess fetal well-being and timing of delivery. Observational studies have indicated that maternal rest in the left lateral position improves maternal cardiac output and uterine blood flow. However, maternal bed rest has not been recommended based on the results of a randomized clinical trial that showed that maternal rest does not improve fetal growth in small-for-gestational-age fetuses. This study was conducted to revisit this question. OBJECTIVE This study aimed to determine whether maternal bed rest was associated with an increase in the fetal biometric parameters that reflect growth after the diagnosis of a small-for-gestational-age fetus. STUDY DESIGN A retrospective study was conducted on fetuses who were diagnosed as small for gestational age because of an estimated fetal weight of <10th percentile for gestational age. The mothers were asked to rest in the left lateral recumbent position. Fetal biometry was performed 2 weeks after the diagnosis. All fetuses before entry into the study had a previous ultrasound that demonstrated an estimated fetal weight of >10th percentile. To assess the response to bed rest, the change in fetal biometric parameters (estimated fetal weight, head circumference, abdominal circumference, and femur length) after the recommendation of bed rest was computed for 2 periods: (1) before the diagnosis of a weight of <10th percentile vs at the time of diagnosis of a weight of <10th percentile and (2) at the time of diagnosis of a weight of <10th percentile vs 2 weeks after maternal bed rest. For repeated measures, proportions were compared using the McNemar test, and percentile values were compared using the Bonferroni Multiple Comparison Test. A P value of <.05 was considered significant. To describe changes in the estimated fetal weight without bed rest, 2 control groups in which the mothers were not placed on bed rest after the diagnosis of a small-for-gestational-age fetus were included. RESULTS A total of 265 fetuses were observed before and after maternal bed rest. The following were observed in this study: (1) after 2 weeks of maternal rest, 199 of 265 fetuses (75%) had a fetal weight of >10th percentile; (2) the median fetal weight percentile increased from 6.8 (interquartile range, 4.4-8.4) to 18.0 (interquartile range, 9.5-29.5) after 2 weeks of bed rest; (3) similar trends were noted for the head circumference, abdominal circumference, and femur length. In the groups of patients who were not asked to be on bed rest, a reassignment to a weight of >10th percentile at a follow-up examination only occurred in 7 of 37 patients (19%) in the Texas-Michigan group and 13 of 111 patients (12%) in the Colorado group compared with the bed rest group (199/265 [75%]) (P<.001). CONCLUSION Patients who were prescribed 2 weeks of bed rest after the diagnosis of a fetal weight of <10th percentile had an increase in weight of >10th percentile in 199 of 265 fetuses (75%). This increase in fetal weight was significantly higher than that in the 2 control groups in which bed rest was not prescribed. This observation suggests that bed rest improves fetal growth in a subset of patients.
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Affiliation(s)
- Greggory R DeVore
- Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA; Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI.
| | - Bardo Polanco
- Fetal Diagnostic Centers, Pasadena, Tarzana, and Lancaster, CA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Jeffrey Brian Fowlkes
- Departments of Radiology and Biomedical Engineering, University of Michigan, Ann Arbor, MI
| | - Emma E Peek
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - Manesha Putra
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
| | - John C Hobbins
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO
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Dogru S, Akkus F, Acar A. Cerebroplacental ratio and perinatal outcomes in mild-to-moderate idiopathic polyhydramnios cases. Int J Gynaecol Obstet 2024; 167:322-329. [PMID: 38666357 DOI: 10.1002/ijgo.15556] [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: 01/26/2024] [Revised: 04/05/2024] [Accepted: 04/09/2024] [Indexed: 09/25/2024]
Abstract
OBJECTIVE This study will evaluate whether fetal cerebroplacental ratio (CPR) can predict perinatal adverse outcomes in singleton pregnancies with mild and moderate idiopathic polyhydramnios (IP). METHOD This study was designed as a prospective case-control study between January 2023 and November 2023. Pregnant women diagnosed with mild-to-moderate IP and low-risk singleton pregnancies were included in the study. In all cases, umbilical artery (UA) and middle cerebral artery (MCA) pulsatility indices (PIs) were measured at 36-40 weeks of gestation, and CPR was calculated. The group with polyhydramnios was divided into two parts according to whether the CPR value was below 1.08 or 1.08 and above. Perinatal outcomes of all groups were compared. RESULTS A total of 140 patients were included in the study. Seventy of these were IP cases, and 70 were low-risk pregnant women. UA PI in the IP group was not statistically different from that in the low-risk group, but MCA PI and CPR were significantly lower in the IP group (P = 0.07, P = 0.001, and P = 0.004, respectively). IP cases were divided into a low group (<1.08, n = 18) and a normal group (≥1.08, n = 52) according to the CPR value. Cesarean section rates due to fetal distress were significantly higher in the low-CPR group (n = 8 [44.4%] vs 5 [9.6%], P = 0.001). In the low-CPR group, 5-min Apgar <7, and neonatal intensive care unit (NICU) admission rates were significantly higher (P = 0.045 and P = 0.001, respectively). CONCLUSION It is encouraging that in cases with mild-to-moderate IP, low CPR predicts emergency delivery due to fetal distress, a low Apgar score at 5 min, and NICU admission.
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Affiliation(s)
- Sukran Dogru
- Division of Fetal and Maternal Medicine, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Fatih Akkus
- Division of Fetal and Maternal Medicine, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
| | - Ali Acar
- Division of Fetal and Maternal Medicine, Department of Obstetrics and Gynecology, Necmettin Erbakan University Medical School of Meram, Konya, Turkey
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Sun H, Ren Y. Correlation between cerebroplacental doppler ratio and neonatal respiratory disorders: A reference marker of fetal lung maturation. Clin Hemorheol Microcirc 2024; 86:275-283. [PMID: 35527541 DOI: 10.3233/ch-211333] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the role of cerebroplacental ratio (CPR) in the final prenatal care for neonatal respiratory diseases and to analyze the risk of relevant factors associated with neonatal respiratory disorders. METHODS A prospective cohort study of 795 singleton pregnancies was conducted. The pulsatility indices (PI) of the umbilical artery (UA) and the middle cerebral artery (MCA) were measured, and the MCA to UA ratio (CPR) was determined. The severity of the case is determined by whether or not the newborn has respiratory problems. Compare the CPR correlation between the two groups and examine the illness prediction factors through a binary logistic regression method. RESULTS Of the 795 participants, 124 had neonatal respiratory disorders. The mean values of CPR between neonatal respiratory diseases group and control group were 1.78±0.6, 1.97±0.9, respectively (P < 0.001). Maternal age, abortion history, cesarean section history, placental thickness, placental maturity, and amniotic fluid index (AFI) were determined to have no significant link between the two groups after comparison analysis (P > 0.05). It could be found that compared with the control group, CPR MoM indicators of neonatal respiratory distress syndrome, neonatal pneumonia and wet lung disease all show significant decreases. In binary logistic regression analysis, among the variables included in the model, CPR (OR:2.90, P = 0.015), fetal heart monitoring (OR:5.26, P < 0.001), delivery mode (OR:2.86, P < 0.001) and gestational age of delivery (OR:0.92, P < 0.001) were statistically significant in both groups. CONCLUSION The findings of this study showed that infant respiratory problems were substantially related to CPR value. The correlation indicates that CPR was a powerful reference marker for respiratory disorders.
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Affiliation(s)
- Hongshuang Sun
- Department of Obstetrics and Gynecology, University of Fudan, Shanghai, China
| | - Yunyun Ren
- Department of Obstetrics and Gynecology, University of Fudan, Shanghai, 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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Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Directive clinique n o 442 : Retard de croissance intra-utérin : Dépistage, diagnostic et prise en charge en contexte de grossesse monofœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102155. [PMID: 37730301 DOI: 10.1016/j.jogc.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIF Le retard de croissance intra-utérin est une complication obstétricale fréquente qui touche jusqu'à 10 % des grossesses dans la population générale et qui est le plus souvent due à une pathologie placentaire sous-jacente. L'objectif de la présente directive clinique est de fournir des déclarations sommaires et des recommandations pour appuyer un protocole clinique de dépistage, diagnostic et prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. POPULATION CIBLE Toutes les patientes enceintes menant une grossesse monofœtale. BéNéFICES, RISQUES ET COûTS: La mise en application des recommandations de la présente directive devrait améliorer la compétence des cliniciens quant à la détection du retard de croissance intra-utérin et à la réalisation des interventions indiquées. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches effectuées jusqu'en septembre 2022 dans les bases de données PubMed, Medline, CINAHL et Cochrane Library en utilisant un vocabulaire contrôlé au moyen de termes MeSH pertinents (fetal growth retardation and small for gestational age) et de mots-clés (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. La littérature grise a été obtenue par des recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle, radiologistes et autres professionnels de la santé qui prodiguent des soins aux patientes enceintes. RéSUMé POUR TWITTER: Mise à jour de la directive sur le dépistage, le diagnostic et la prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS: Prédiction du retard de croissance intra-utérin Prévention du retard de croissance intra-utérin Détection du retard de croissance intra-utérin Examens en cas de retard de croissance intra-utérin soupçonné Prise en charge du retard de croissance intra-utérin précoce Prise en charge du retard de croissance intra-utérin tardif Prise en charge du post-partum et consultations préconception.
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Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Guideline No. 442: Fetal Growth Restriction: Screening, Diagnosis, and Management in Singleton Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102154. [PMID: 37730302 DOI: 10.1016/j.jogc.2023.05.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Fetal growth restriction is a common obstetrical complication that affects up to 10% of pregnancies in the general population and is most commonly due to underlying placental diseases. The purpose of this guideline is to provide summary statements and recommendations to support a clinical framework for effective screening, diagnosis, and management of pregnancies that are either at risk of or affected by fetal growth restriction. TARGET POPULATION All pregnant patients with a singleton pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase clinician competency to detect fetal growth restriction and provide appropriate interventions. EVIDENCE Published literature in English was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library through to September 2022 using appropriate controlled vocabulary via MeSH terms (fetal growth retardation and small for gestational age) and key words (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Grey literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for pregnant patients. TWEETABLE ABSTRACT Updated guidelines on screening, diagnosis, and management of pregnancies at risk of or affected by FGR. SUMMARY STATEMENTS RECOMMENDATIONS: Prediction of FGR Prevention of FGR Detection of FGR Investigations in Pregnancies with Suspected Fetal Growth Restriction Management of Early-Onset Fetal Growth Restriction Management of Late-Onset FGR Postpartum management and preconception counselling.
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Miranda J, Paules C, Noell G, Youssef L, Paternina-Caicedo A, Crovetto F, Cañellas N, Garcia-Martín ML, Amigó N, Eixarch E, Faner R, Figueras F, Simões RV, Crispi F, Gratacós E. Similarity network fusion to identify phenotypes of small-for-gestational-age fetuses. iScience 2023; 26:107620. [PMID: 37694157 PMCID: PMC10485038 DOI: 10.1016/j.isci.2023.107620] [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: 01/05/2023] [Revised: 04/19/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Fetal growth restriction (FGR) affects 5-10% of pregnancies, is the largest contributor to fetal death, and can have long-term consequences for the child. Implementation of a standard clinical classification system is hampered by the multiphenotypic spectrum of small fetuses with substantial differences in perinatal risks. Machine learning and multiomics data can potentially revolutionize clinical decision-making in FGR by identifying new phenotypes. Herein, we describe a cluster analysis of FGR based on an unbiased machine-learning method. Our results confirm the existence of two subtypes of human FGR with distinct molecular and clinical features based on multiomic analysis. In addition, we demonstrated that clusters generated by machine learning significantly outperform single data subtype analysis and biologically support the current clinical classification in predicting adverse maternal and neonatal outcomes. Our approach can aid in the refinement of clinical classification systems for FGR supported by molecular and clinical signatures.
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Affiliation(s)
- Jezid Miranda
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Cartagena, Cartagena de Indias, Colombia
| | - Cristina Paules
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Aragon Institute of Health Research (IIS Aragon), Obstetrics Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Guillaume Noell
- University of Barcelona, Biomedicine Department, IDIBAPS, Centre for Biomedical Research on Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Lina Youssef
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | | | - Francesca Crovetto
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Nicolau Cañellas
- Metabolomics Platform, IISPV, DEEiA, Universidad Rovira i Virgili, Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Tarragona, Spain
| | - María L. Garcia-Martín
- BIONAND, Andalusian Centre for Nanomedicine and Biotechnology, Junta de Andalucía, Universidad de Málaga, Málaga, Spain
| | | | - Elisenda Eixarch
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Rosa Faner
- University of Barcelona, Biomedicine Department, IDIBAPS, Centre for Biomedical Research on Respiratory Diseases (CIBERES), Barcelona, Spain
| | - Francesc Figueras
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Rui V. Simões
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
- Institute for Research & Innovation in Health (i3S), University of Porto, Porto, Portugal
| | - Fàtima Crispi
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacós
- BCNatal – Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, and Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Peasley R, Rangel LAA, Casagrandi D, Donadono V, Willinger M, Conti G, Seminara Y, Marlow N, David AL, Attilakos G, Pandya P, Zaikin A, Peebles D, Napolitano R. Management of late-onset fetal growth restriction: pragmatic approach. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:106-114. [PMID: 36864542 DOI: 10.1002/uog.26190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 02/08/2023] [Accepted: 02/15/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVES There is limited prospective evidence to guide the management of late-onset fetal growth restriction (FGR) and its differentiation from small-for-gestational age. The aim of this study was to assess prospectively a novel protocol in which ultrasound criteria were used to classify women with suspected late FGR into two groups: those at low risk, who were managed expectantly until the anticipated date of delivery, and those at high risk, who were delivered soon after 37 weeks of gestation. We also compared the outcome of this prospective cohort with that of a historical cohort of women presenting similarly with suspected late FGR, in order to evaluate the impact of the new protocol. METHODS This was a prospective study of women with a non-anomalous singleton pregnancy at ≥ 32 weeks' gestation attending a tertiary hospital in London, UK, between February 2018 and September 2019, with estimated fetal weight (EFW) ≤ 10th centile, or EFW > 10th centile in addition to a decrease in fetal abdominal circumference of ≥ 50 centiles compared with a previous scan, umbilical artery Doppler pulsatility index > 95th centile or cerebroplacental ratio < 5th centile. Women were classified as low or high risk based on ultrasound and Doppler criteria. Women in the low-risk group were delivered by 41 weeks of gestation, unless they subsequently met high-risk criteria, whereas women in the high-risk group (EFW < 3rd centile, umbilical artery Doppler pulsatility index > 95th centile or EFW between 3rd and 10th centiles (inclusive) with abdominal circumference drop or abnormal Dopplers) were delivered at or soon after 37 weeks. The primary outcome was adverse neonatal outcome and included hypothermia, hypoglycemia, neonatal unit admission, jaundice requiring treatment, suspected infection, feeding difficulties, 1-min Apgar score < 7, hospital readmission and any severe adverse neonatal outcome (perinatal death, resuscitation using inotropes or mechanical ventilation, 5-min Apgar score < 7, metabolic acidosis, sepsis, and cerebral, cardiac or respiratory morbidity). Secondary outcomes were adverse maternal outcome (operative delivery for abnormal fetal heart rate) and severe adverse neonatal outcome. Women managed according to the new protocol were compared with a historical cohort of 323 women delivered prior to the implementation of the new protocol, for whom management was guided by individual clinician expertise. RESULTS Over 18 months, 321 women were recruited to the prospective cohort, of whom 156 were classified as low risk and 165 were high risk. Adverse neonatal outcome was significantly less common in the low-risk compared with the high-risk group (45% vs 58%; adjusted odds ratio (aOR), 0.6 (95% CI, 0.4-0.9); P = 0.022). There was no significant difference in the rate of adverse maternal outcome (18% vs 24%; aOR, 0.7 (95% CI, 0.4-1.2); P = 0.142) or severe adverse neonatal outcome (3.8% vs 8.5%; aOR, 0.5 (95% CI, 0.2-1.3); P = 0.153) between the low- and high-risk groups. Compared with women in the historical cohort classified retrospectively as low risk, low-risk women managed under the new protocol had a lower rate of adverse neonatal outcome (45% vs 58%; aOR, 0.6 (95% CI, 0.4-0.9); P = 0.026). CONCLUSIONS Appropriate risk stratification to guide management of late FGR was associated with a reduced rate of adverse neonatal outcome in low-risk pregnancies. In clinical practice, a policy of expectantly managing women with a low-risk late-onset FGR pregnancy at term could improve neonatal and long-term development. Randomized controlled trials are needed to assess the effect of an evidence-based conservative management protocol for late FGR on perinatal morbidity and mortality and long-term neurodevelopment. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Peasley
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - L A Abrego Rangel
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Department of Mathematics, University College London, London, UK
| | - D Casagrandi
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - V Donadono
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Willinger
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Conti
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - Y Seminara
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Marlow
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - A L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - G Attilakos
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - P Pandya
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Zaikin
- Department of Women's Cancer, Institute for Women's Health, University College London, London, UK
- Department of Mathematics, University College London, London, UK
| | - D Peebles
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
- National Institute for Health Research, University College London Hospitals Biomedical Research Centre, University College London, London, UK
| | - R Napolitano
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
- Fetal Medicine Unit, Elizabeth Garrett Anderson Wing, University College London Hospitals NHS Foundation Trust, London, UK
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Devi G G, Balakrishnan B, Batra M, Patil SN, Madhusoodanan L, Hooda R, Kk G. Role of global sphericity index in evaluation of fetal cardiac remodeling in late onset fetal growth restriction and small for gestational age fetuses. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:796-802. [PMID: 36929508 DOI: 10.1002/jcu.23448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 06/02/2023]
Abstract
INTRODUCTION Fetal growth restriction (FGR) fetuses develop cardiovascular remodeling and dysfunction and, in this process, heart first compensates by changing its shape from ellipsoid to spherical and then cardiac dysfunction follows. Our aim was to evaluate global sphericity index (GSI) after 32 weeks of gestation to evaluate this change in cardiac shape and correlate GSI changes associated with fetal growth abnormalities. MATERIALS AND METHODS This was a prospective study conducted at 32-38 weeks of gestation. Women were classified into three groups-Appropriate for gestational age (AGA), small for gestational age (SGA), late onset FGR (LO FGR) and GSI was measured and perinatal outcome studied. RESULTS Out of 217 women, 131 were of AGA, 31 were SGA, 55 were of late onset FGR. SGA and late onset FGR groups had low GSI compared to AGA group. There was no significant difference in mean GSI between late onset FGR and SGA groups. Neonatal morbidity, adverse perinatal outcomes did not significantly differ with GSI in SGA and late onset FGR groups. CONCLUSION This study showed that late gestation small fetuses develop early stages of cardiovascular remodeling as shown by GSI changes. These changes were independent of Doppler changes. This supports the concept that atleast a proportion of them are not constitutionally small but are true forms of FGR.
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Affiliation(s)
- Geeta Devi G
- Fellow NBE, Maternal and Fetal Medicine, CIMAR, Edappal Hospital, Edappal, Malappuram, India
| | - Bijoy Balakrishnan
- Consultant, Department of Maternal and Fetal Medicine, CIMAR, Edappal Hospital, Edappal, Malappuram, India
| | - Meenu Batra
- Consultant, Department of Maternal and Fetal Medicine, CIMAR, Kochi, India
| | - Swapneel Nilkanth Patil
- Consultant, Department of Maternal and Fetal Medicine, CIMAR, Edappal Hospital, Edappal, Malappuram, India
| | - Lipi Madhusoodanan
- Consultant, Department of Maternal and Fetal Medicine, CIMAR, Edappal Hospital, Edappal, Malappuram, India
| | - Ruchi Hooda
- Fellow NBE, Department of Reproductive Medicine, CIMAR, Edappal Hospital, Edappal, Malappuram, India
| | - Gopinathan Kk
- Head of Department of Reproductive Medicine, CIMAR, Edappal, Malappuram, India
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Demirdjian SP, Meller CH, Berruet MC, Dosdoglirian G, Etchegaray A. Perinatal outcomes of two consecutive strategies for the management of fetal growth restriction: a before-after study. Arch Gynecol Obstet 2023; 307:319-326. [PMID: 35688941 DOI: 10.1007/s00404-022-06641-x] [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: 02/25/2022] [Accepted: 05/18/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE We aim to compare the perinatal outcomes of two consecutive management strategies for fetal growth restriction (FGR), with or without the inclusion of additional Doppler parameters. METHODS A quasi-experimental before/after study was conducted in which we compared a composite perinatal outcome, prematurity rate, and neonatal complications between two management strategies in small fetuses. In the strategy 1 (S1), the management was based on fetal biometry and umbilical artery Doppler. The second strategy (S2) added the assessment of uterine and middle cerebral artery Doppler. We also compared outcomes between strategies according to early (≤ 32 weeks) and late (> 32 weeks) diagnosis subgroups. RESULTS We included 396 patients, 163 in S1 and 233 in S2. There were no significant differences in the perinatal composite outcome (p 0.98), prematurity (p 0.19), or in the subgroup analysis. We found a significant reduction in respiratory distress syndrome (RDS) rate with S2 both globally (OR 0.50, p 0.02), and in the early diagnosis subgroup (OR 0.45, p 0.01). In addition, we observed a significant reduction in the incidence of sepsis with S2 both globally (OR 0.30, p 0.04) and in the early diagnosis subgroup (OR 0.25, p 0.02). We did not observe significant differences in necrotizing enterocolitis (p 0.41) and intraventricular hemorrhage (p 1.00). CONCLUSION The expanded strategy for the management of FGR did not show significant differences in the primary composite outcome or prematurity. However, it was associated with a lower incidence of RDS and neonatal sepsis.
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Affiliation(s)
- Sabrina Paola Demirdjian
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Austral, Buenos Aires, Argentina.
| | - Cesar Hernan Meller
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Italiano de Buenos Aires, Instituto Universitario Hospital Italiano, Buenos Aires, Argentina
| | - Maria Celeste Berruet
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Gonzalo Dosdoglirian
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Adolfo Etchegaray
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Universitario Austral, Buenos Aires, Argentina
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11
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Villalain C, Galindo A, Di Mascio D, Buca D, Morales-Rosello J, Loscalzo G, Giulia Sileo F, Finarelli A, Bertucci E, Facchinetti F, Rizzo G, Brunelli R, Giancotti A, Muzii L, Maruotti GM, Carbone L, D'Amico A, Tinari S, Morelli R, Cerra C, Nappi L, Greco P, Liberati M, D'Antonio F, Herraiz I. Diagnostic performance of cerebroplacental and umbilicocerebral ratio in appropriate for gestational age and late growth restricted fetuses attempting vaginal delivery: a multicenter, retrospective study. J Matern Fetal Neonatal Med 2022; 35:6853-6859. [PMID: 34102939 DOI: 10.1080/14767058.2021.1926977] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/04/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cerebroplacental Doppler studies have been advocated to predict the risk of adverse perinatal outcome (APO) irrespective of fetal weight. OBJECTIVE To report the diagnostic performance of cerebroplacental (CPR) and umbilicocerebral (UCR) ratios in predicting APO in appropriate for gestational age (AGA) fetuses and in those affected by late fetal growth restriction (FGR) attempting vaginal delivery. STUDY DESIGN Multicenter, retrospective, nested case-control study between 1 January 2017 and January 2020 involving five referral centers in Italy and Spain. Singleton gestations with a scan between 36 and 40 weeks and within two weeks of attempting vaginal delivery were included. Fetal arterial Doppler and biometry were collected. The AGA group was defined as fetuses with an estimated fetal weight and abdominal circumference >10th and <90th percentile, while the late FGR group was defined by Delphi consensus criteria. The primary outcome was the prediction of a composite of perinatal adverse outcomes including either intrauterine death, Apgar score at 5 min <7, abnormal acid-base status (umbilical artery pH < 7.1 or base excess of more than -11) and neonatal intensive care unit (NICU) admission. Area under the curve (AUC) analysis was performed. RESULTS 646 pregnancies (317 in the AGA group and 329 in the late FGR group) were included. APO were present in 12.6% AGA and 24.3% late FGR pregnancies, with an odds ratio of 2.22 (95% CI 1.46-3.37). The performance of CPR and UCR for predicting APO was poor in both AGA [AUC: 0.44 (0.39-0.51)] and late FGR fetuses [AUC: 0.56 (0.49-0.61)]. CONCLUSIONS CPR and UCR on their own are poor prognostic predictors of APO irrespective of fetal weight.
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Affiliation(s)
- Cecilia Villalain
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Alberto Galindo
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Danilo Buca
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Jose Morales-Rosello
- Servicio de Obstetricia y Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Gabriela Loscalzo
- Servicio de Obstetricia y Ginecología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Filomena Giulia Sileo
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Finarelli
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Emma Bertucci
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabio Facchinetti
- Prenatal Medicine Unit, Obstetrics and Gynecology Unit, Department of Medical and Surgical Sciences for Mother, Child and Adult, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Rizzo
- Università di Roma Tor Vergata, Division of Maternal Fetal Medicine, Ospedale Cristo Re, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Roberto Brunelli
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Antonella Giancotti
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Maria Maruotti
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luigi Carbone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Alice D'Amico
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Sara Tinari
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Roberta Morelli
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Chiara Cerra
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, Foggia, Italy
| | - Pantaleo Greco
- Department of Morphology, Surgery and Experimental Medicine, Institute of Obstetrics and Gynaecology, University of Ferrara, Ferrara, Italy
| | - Marco Liberati
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Department of Obstetrics and Gynecology, Center for High Risk Pregnancy and Fetal Care, University of Chieti, Chieti, Italy
| | - Ignacio Herraiz
- Fetal Medicine Unit, Maternal and Child Health and Development Network, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University of Madrid, Madrid, Spain
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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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Ruiz-Martinez S, Delgado JL, Paules C, Cavallaro A, De Paco C, Villar J, Papageorghiou A, Oros D. Clinical phenotypes for risk stratification in small-for-gestational-age fetuses. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:490-496. [PMID: 34396614 DOI: 10.1002/uog.23765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/22/2021] [Accepted: 08/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate whether clinical phenotypes of small-for-gestational-age (SGA) fetuses can be identified and used for adverse perinatal outcome risk stratification to facilitate clinical decision-making. METHODS This was a multicenter observational cohort study conducted in two tertiary care university hospitals. SGA fetuses were classified according to maternal, fetal and placental conditions using a two-step cluster algorithm, in which fetuses with more than one condition were assigned to the cluster associated with the highest mortality risk. Delivery and perinatal outcomes were compared using chi-square test among SGA clusters, and the associations between outcomes and each cluster were evaluated by calculating odds ratios (OR), adjusted for gestational age. RESULTS The study included 17 631 consecutive singleton pregnancies, of which 1274 (7.2%) were defined as SGA at birth according to INTERGROWTH-21st standards. Nine SGA clinical phenotypes were identified using a predefined conceptual framework. All delivery and perinatal outcomes analyzed were significantly different among the nine phenotypes. The whole SGA cohort had a three-times higher risk of perinatal mortality compared with non-SGA fetuses (1.4% vs 0.4%; P < 0.001). SGA clinical phenotypes exhibited three patterns of perinatal mortality risk: the highest risk was associated with congenital anomaly (8.3%; OR, 17.17 (95% CI, 2.17-136.12)) and second- or third-trimester hemorrhage (8.3%; OR, 9.94 (95% CI, 1.23-80.02)) clusters; medium risk was associated with gestational diabetes (3.8%; OR, 9.59 (95% CI, 1.27-72.57)), preterm birth (3.2%; OR, 4.65 (95% CI, 0.62-35.01)) and intrauterine growth restriction (3.1%; OR, 5.93 (95% CI, 3.21-10.95)) clusters; and the lowest risk was associated with the remaining clusters. Perinatal mortality rate did not differ between SGA fetuses without other clinical conditions (54.1% of SGA fetuses) and appropriate-for-gestational-age fetuses (0.1% vs 0.4%; OR, 0.41 (95% CI, 0.06-2.94); P = 0.27). SGA combined with other obstetric pathologies increased significantly the risk of perinatal mortality, as demonstrated by the increased odds of perinatal death in SGA cases with gestational diabetes compared to non-SGA cases with the same condition (OR, 24.40 (95% CI, 1.31-453.91)). CONCLUSIONS We identified nine SGA clinical phenotypes associated with different patterns of risk for adverse perinatal outcome. Our findings suggest that considering clinical characteristics in addition to ultrasound findings could improve risk stratification and decision-making for management of SGA fetuses. Future clinical trials investigating management of fetuses with SGA should take into account clinical information in addition to Doppler parameters and estimated fetal weight. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S Ruiz-Martinez
- Aragon Institute of Health Research (IIS Aragon), Obstetrics Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Red de Salud Materno Infantil y del Desarrollo (SAMID), RETICS, Instituto de Salud Carlos III (ISCIII), Subdirección General de Evaluación y Fomento de la Investigación y Fondo Europeo de Desarrollo Regional (FEDER), Spain
| | - J L Delgado
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario 'Virgen de la Arrixaca', El Palmar, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain
| | - C Paules
- Aragon Institute of Health Research (IIS Aragon), Obstetrics Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Red de Salud Materno Infantil y del Desarrollo (SAMID), RETICS, Instituto de Salud Carlos III (ISCIII), Subdirección General de Evaluación y Fomento de la Investigación y Fondo Europeo de Desarrollo Regional (FEDER), Spain
| | - A Cavallaro
- Nuffield Department of Obstetrics and Gynaecology, Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - C De Paco
- Department of Obstetrics and Gynecology, Hospital Clínico Universitario 'Virgen de la Arrixaca', El Palmar, Murcia, Spain
- Institute for Biomedical Research of Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain
| | - J Villar
- Nuffield Department of Obstetrics and Gynaecology, Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - A Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - D Oros
- Aragon Institute of Health Research (IIS Aragon), Obstetrics Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Red de Salud Materno Infantil y del Desarrollo (SAMID), RETICS, Instituto de Salud Carlos III (ISCIII), Subdirección General de Evaluación y Fomento de la Investigación y Fondo Europeo de Desarrollo Regional (FEDER), Spain
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Dall'Asta A, Stampalija T, Mecacci F, Minopoli M, Schera GBL, Cagninelli G, Ottaviani C, Fantasia I, Barbieri M, Lisi F, Simeone S, Ghi T, Frusca T. Ultrasound prediction of adverse perinatal outcome at diagnosis of late-onset fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:342-349. [PMID: 34159652 PMCID: PMC9313890 DOI: 10.1002/uog.23714] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the relationship between Doppler and biometric ultrasound parameters measured at diagnosis and perinatal adverse outcome in a cohort of late-onset growth-restricted (FGR) fetuses. METHODS This was a multicenter retrospective study of data obtained between 2014 and 2019 including non-anomalous singleton pregnancies complicated by late-onset FGR (≥ 32 weeks), which was defined either as abdominal circumference (AC) or estimated fetal weight (EFW) < 10th percentile for gestational age or as reduction of the longitudinal growth of AC by over 50 percentiles compared to ultrasound scan performed between 18 and 32 weeks of gestation. We evaluated the association between sonographic findings at diagnosis of FGR and composite adverse perinatal outcome (CAPO), defined as stillbirth or at least two of the following: obstetric intervention due to intrapartum fetal distress, neonatal acidemia, birth weight < 3rd percentile and transfer to the neonatal intensive care unit (NICU). RESULTS Overall, 468 cases with complete biometric and umbilical, fetal middle cerebral and uterine artery (UtA) Doppler data were included, of which 53 (11.3%) had CAPO. On logistic regression analysis, only EFW percentile was associated independently with CAPO (P = 0.01) and NICU admission (P < 0.01), while the mean UtA pulsatility index (PI) multiples of the median (MoM) > 95th percentile at diagnosis was associated independently with obstetric intervention due to intrapartum fetal distress (P = 0.01). The model including baseline pregnancy characteristics and the EFW percentile was associated with an area under the receiver-operating-characteristics curve of 0.889 (95% CI, 0.813-0.966) for CAPO (P < 0.001). A cut-off value for EFW corresponding to the 3.95th percentile was found to discriminate between cases with and those without CAPO, yielding a sensitivity of 58.5% (95% CI, 44.1-71.9%), specificity of 69.6% (95% CI, 65.0-74.0%), positive predictive value of 19.8% (95% CI, 13.8-26.8%) and negative predictive value of 92.9% (95% CI, 89.5-95.5%). CONCLUSIONS Retrospective data from a large cohort of late-onset FGR fetuses showed that EFW at diagnosis is the only sonographic parameter associated independently with the occurrence of CAPO, while mean UtA-PI MoM > 95th percentile at diagnosis is associated independently with intrapartum distress leading to obstetric intervention. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. Dall'Asta
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - T. Stampalija
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
- Department of MedicineSurgery and Health Sciences, University of TriesteTriesteItaly
| | - F. Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and GynecologyUniversity of FlorenceFlorenceItaly
| | - M. Minopoli
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - G. B. L. Schera
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - G. Cagninelli
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - C. Ottaviani
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
| | - I. Fantasia
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
| | - M. Barbieri
- Unit of Fetal Medicine and Prenatal DiagnosisInstitute for Maternal and Child Health IRCCS Burlo GarofoloTriesteItaly
| | - F. Lisi
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and GynecologyUniversity of FlorenceFlorenceItaly
| | - S. Simeone
- Department of Biomedical, Experimental and Clinical Sciences, Division of Obstetrics and GynecologyUniversity of FlorenceFlorenceItaly
| | - T. Ghi
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
| | - T. Frusca
- Department of Medicine and Surgery, Unit of Surgical Sciences, Obstetrics and GynecologyUniversity of ParmaParmaItaly
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Garcia-Manau P, Mendoza M, Bonacina E, Martin-Alonso R, Martin L, Palacios A, Sanchez ML, Lesmes C, Hurtado I, Perez E, Tubau A, Ibañez P, Alcoz M, Valiño N, Moreno E, Borrero C, Garcia E, Lopez-Quesada E, Diaz S, Broullon JR, Teixidor M, Chulilla C, Gil MM, Lopez M, Candela-Hidalgo A, Salinas-Amoros A, Moreno A, Morra F, Vaquerizo O, Soriano B, Fabre M, Gomez-Valencia E, Cuiña A, Alayon N, Sainz JA, Vives A, Esteve E, Ocaña V, López MÁ, Maroto A, Carreras E. Management of fetal Growth Restriction at term by Angiogenic Factors versus feto-maternal Doppler (GRAFD) to avoid adverse perinatal outcomes: multicenter open-label randomized controlled trial study protocol (Preprint). JMIR Res Protoc 2022; 11:e37452. [PMID: 36222789 PMCID: PMC9597418 DOI: 10.2196/37452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background Fetal smallness affects 10% of pregnancies. Small fetuses are at a higher risk of adverse outcomes. Their management using estimated fetal weight and feto-maternal Doppler has a high sensitivity for adverse outcomes; however, more than 60% of fetuses are electively delivered at 37 to 38 weeks. On the other hand, classification using angiogenic factors seems to have a lower false-positive rate. Here, we present a protocol for the Fetal Growth Restriction at Term Managed by Angiogenic Factors Versus Feto-Maternal Doppler (GRAFD) trial, which compares the use of angiogenic factors and Doppler to manage small fetuses at term. Objective The primary objective is to demonstrate that classification based on angiogenic factors is not inferior to estimated fetal weight and Doppler at detecting fetuses at risk of adverse perinatal outcomes. Methods This is a multicenter, open-label, randomized controlled trial conducted in 20 hospitals across Spain. A total of 1030 singleton pregnancies with an estimated fetal weight ≤10th percentile at 36+0 to 37+6 weeks+days will be recruited and randomly allocated to either the control or the intervention group. In the control group, standard Doppler-based management will be used. In the intervention group, cases with a soluble fms-like tyrosine kinase to placental growth factor ratio ≥38 will be classified as having fetal growth restriction; otherwise, they will be classified as being small for gestational age. In both arms, the fetal growth restriction group will be delivered at ≥37 weeks and the small for gestational age group at ≥40 weeks. We will assess differences between the groups by calculating the relative risk, the absolute difference between incidences, and their 95% CIs. Results Recruitment for this study started on September 28, 2020. The study results are expected to be published in peer-reviewed journals and disseminated at international conferences in early 2023. Conclusions The angiogenic factor–based protocol may reduce the number of pregnancies classified as having fetal growth restriction without worsening perinatal outcomes. Moreover, reducing the number of unnecessary labor inductions would reduce costs and the risks derived from possible iatrogenic complications. Additionally, fewer inductions would lower the rate of early-term neonates, thus improving neonatal outcomes and potentially reducing long-term infant morbidities. Trial Registration ClinicalTrials.gov NCT04502823; https://clinicaltrials.gov/ct2/show/NCT04502823 International Registered Report Identifier (IRRID) DERR1-10.2196/37452
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Affiliation(s)
- Pablo Garcia-Manau
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Manel Mendoza
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Erika Bonacina
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raquel Martin-Alonso
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de Torrejón, Madrid, Spain
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Lourdes Martin
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari de Tarragona Joan XXIII, Universitat Rovira i Virgili, Tarragona, Spain
| | - Ana Palacios
- Department of Obstetrics, Alicante University General Hospital, Miguel Hernandez University, Alicante, Spain
- Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Maria Luisa Sanchez
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Cristina Lesmes
- Maternal Fetal Medicine Unit, Department of Obstetrics, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Ivan Hurtado
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Esther Perez
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de Cabueñes, Universidad de Oviedo, Gijón, Spain
| | - Albert Tubau
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Son Llàtzer, Universitat de les Illes Balears, Palma de Mallorca, Spain
| | - Patricia Ibañez
- Aragon Institute for Health Research, Department of Obstetrics, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Marina Alcoz
- Maternal Fetal Medicine Unit, Department of Obstetrics, Fundació Althaia, Universitat de Vic, Manresa, Spain
| | - Nuria Valiño
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de A Coruña, Universidade da Coruña, A Coruña, Spain
| | - Elena Moreno
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital General Universitario de Elche, Universidad Miguel Hernández, Elche, Spain
| | - Carlota Borrero
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario Virgen de Valme, Universidad de Sevilla, Sevilla, Spain
| | - Esperanza Garcia
- Maternal Fetal Medicine Unit, Department of Obstetrics, Consorci Sanitari de Terrassa, Universitat Internacional de Catalunya, Terrassa, Spain
| | - Eva Lopez-Quesada
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Terrassa, Spain
| | - Sonia Diaz
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de Getafe, Universidad Europea de Madrid, Getafe, Spain
| | - Jose Roman Broullon
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario Puerta del Mar, Universidad de Cádiz, Cádiz, Spain
| | - Mireia Teixidor
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari de Girona Doctor Josep Trueta, Universitat de Girona, Girona, Spain
| | - Carolina Chulilla
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario Nuestra Señora de Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Maria M Gil
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de Torrejón, Madrid, Spain
- School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - Monica Lopez
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari de Tarragona Joan XXIII, Universitat Rovira i Virgili, Tarragona, Spain
| | - Amparo Candela-Hidalgo
- Department of Obstetrics, Alicante University General Hospital, Miguel Hernandez University, Alicante, Spain
- Alicante Institute for Health and Biomedical Research, Alicante, Spain
| | - Andrea Salinas-Amoros
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Anna Moreno
- Maternal Fetal Medicine Unit, Department of Obstetrics, Parc Taulí Hospital Universitari, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Francesca Morra
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Oscar Vaquerizo
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de Cabueñes, Universidad de Oviedo, Gijón, Spain
| | - Beatriz Soriano
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Son Llàtzer, Universitat de les Illes Balears, Palma de Mallorca, Spain
| | - Marta Fabre
- Aragon Institute for Health Research, Department of Obstetrics, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Elena Gomez-Valencia
- Maternal Fetal Medicine Unit, Department of Obstetrics, Fundació Althaia, Universitat de Vic, Manresa, Spain
| | - Ana Cuiña
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de A Coruña, Universidade da Coruña, A Coruña, Spain
| | - Nicolas Alayon
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital General Universitario de Elche, Universidad Miguel Hernández, Elche, Spain
| | - Jose Antonio Sainz
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario Virgen de Valme, Universidad de Sevilla, Sevilla, Spain
| | - Angels Vives
- Maternal Fetal Medicine Unit, Department of Obstetrics, Consorci Sanitari de Terrassa, Universitat Internacional de Catalunya, Terrassa, Spain
| | - Esther Esteve
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Terrassa, Spain
| | - Vanesa Ocaña
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario de Getafe, Universidad Europea de Madrid, Getafe, Spain
| | - Miguel Ángel López
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitario Puerta del Mar, Universidad de Cádiz, Cádiz, Spain
| | - Anna Maroto
- Maternal Fetal Medicine Unit, Department of Obstetrics, Hospital Universitari de Girona Doctor Josep Trueta, Universitat de Girona, Girona, Spain
| | - Elena Carreras
- Maternal Fetal Medicine Unit, Department of Obstetrics, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
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Marasciulo F, Orabona R, Fratelli N, Fichera A, Valcamonico A, Ferrari F, Odicino FE, Sartori E, Prefumo F. Preeclampsia and late fetal growth restriction. Minerva Obstet Gynecol 2021; 73:435-441. [PMID: 33949823 DOI: 10.23736/s2724-606x.21.04809-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
There is a strong but complex relationship between fetal growth restriction and preeclampsia. According to the International Society for the Study of Hypertension in Pregnancy the coexistence of gestational hypertension and fetal growth restriction identifies preeclampsia with no need for other signs of maternal organ impairment. While early-onset fetal growth restriction and preeclampsia are often strictly associated, such association becomes looser in the late preterm and term periods. The incidence of preeclampsia decreases dramatically from early preterm fetal growth restriction (39-43%) to late preterm fetal growth restriction (9-32%) and finally to term fetal growth restriction (4-7%). Different placental and cardiovascular mechanism underlie this trend: isolated fetal growth restriction has less frequent placental vascular lesions than fetal growth restriction associated with preeclampsia; moreover, late preterm and term fetal growth restriction show different patterns of maternal cardiac output and peripheral vascular resistance in comparison with preeclampsia. Consequently, current strategies for first trimester screening of placental dysfunction, originally implemented for preeclampsia, do not perform well for late-onset fetal growth restriction: the sensitivity of first trimester combined screening for small-for-gestational age newborns delivered at less than 32 weeks is 56-63%, and progressively decreases for those delivered at 32-36 weeks (43-48%) or at term (21-26%). Moreover, while the test is more sensitive for small-for-gestational age associated with preeclampsia at any gestational age, its sensitivity is much lower for small-for-gestational age without preeclampsia at 32-36 weeks (31-37%) or at term (19-23%).
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Affiliation(s)
- Francesco Marasciulo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Rossana Orabona
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Nicola Fratelli
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Anna Fichera
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Adriana Valcamonico
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Federico Ferrari
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Franco E Odicino
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Enrico Sartori
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Federico Prefumo
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Sciences, ASST Spedali Civili, University of Brescia, Brescia, Italy -
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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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Meler E, Martínez J, Boada D, Mazarico E, Figueras F. Doppler studies of placental function. Placenta 2021; 108:91-96. [PMID: 33857819 DOI: 10.1016/j.placenta.2021.03.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 02/18/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Placental-associated diseases account for most cases of adverse perinatal outcome in developing countries. Doppler evaluation has been incorporated as a predictive parameter at early pregnancy for high-risk placental disease, in the diagnosis and management of those fetuses with impaired intrauterine growth and for the evaluation of fetal wellbeing in those high-risk pregnancies. Uterine Doppler at second trimester predicts most instances of early-onset preeclampsia and intrauterine growth restriction. However, the growing evidence of an effective early propylactic strategy, has turned Uterine Doppler an essential parameter to be included in first trimester predictive algorithms. Umbilical artery Doppler helps in the identification of small-for-gestational-age fetuses at higher risk, and is one of the essential vessels in the assessment of fetal hypoxia impairment, especially in the early cases. It helps in the decision timing for ending the pregnancy improving thus perinatal outcomes. Moreover, in high-risk pregnancies, umbilical artery Doppler has demonstrated to reduce the risk of perinatal deaths and the risk of obstetric interventions. On the other hand, middle cerebral artery Doppler reflects fetal adaptation to hypoxia, and with the cerebroplacental ratio, they improve the detection of fetuses a high risk of adverse perinatal outcome, mostly of those late small fetuses, where most instances of adverse outcome occur in fetuses with normal umbilical artery. Ductus venosous Doppler waveform is a surrogate parameter of the fetal base-acid status. Its use has demonstrated to improve perinatal outcomes, mainly reducing the risk of fetal intrauterine death. Alone or in combination with computerized CTG, it helps tailoring the best moment to end the pregnancy among early cases.
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Affiliation(s)
- Eva Meler
- 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.
| | - Judit Martínez
- 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
| | - David Boada
- 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
| | - Edurne Mazarico
- 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
| | - Francesc Figueras
- 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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