Absent or reversed end-diastolic blood flow in the umbilical artery and abnormal Doppler cerebroplacental ratio--cognitive, neurological and somatic development at 3 to 6 years

Presumed etiology of preterm birth: brain injury and neurodevelopmental outcomes

AIM

To determine the relationship between presumed preterm birth (PTB) etiology and the incidence of brain injury, and neurodevelopmental outcomes at 3 and 4.5 years.

SUBJECTS AND METHODS

Prospective cohort study including 222 neonates born at 24-32 weeks' gestation. The presumed PTB etiology was defined by placental histopathology and other clinical features. Outcome measures included brain injury defined on MRI, neurodevelopmental outcomes using the Bayley Scales of Infant and Toddler Development, the Movement Assessment Battery for Children, Wechsler Preschool and Primary Scale of Intelligence, Beery Buktenica Developmental Test of Visual-Motor Integration.

RESULTS

Presumed PTB etiology was inflammatory in 85 (38%), vascular in 57 (25%), multiple gestation in 56 (25%) and idiopathic in 24 (11%) neonates. Cognitive outcome at 3 years was marginally lower in the inflammatory group (Beta = -6.2, P = 0.05) relative to multiple gestation. At 4.5 years, white matter injury was associated with significantly lower motor scores (P = 0.004) and there were no significant associations between PTB etiology and WPPSI-III IQ scales or MABC-2 scores.

CONCLUSIONS

The lack of association between presumed PTB etiology (using integrated clinical phenotype and placental pathology) and cognitive/motor outcomes suggests that postnatal morbidities and brain injury are pivotal in the neurodevelopmental trajectory of these infants.

IMPACT

The presumed etiology of preterm birth (PTB), based on placental histopathology and clinical features, does not predict long-term neurodevelopmental outcomes, such as cognitive scores at 4.5 years. Postnatal factors, including neonatal morbidities (e.g., bronchopulmonary dysplasia, retinopathy of prematurity, brain injury), are more significant in determining neurodevelopmental outcomes than the initial PTB cause. Placental histopathology helps identify PTB causes but shows no direct link to brain injury or neurodevelopmental outcomes. Infants with "idiopathic" PTB (no clear cause) have the greatest white matter injury burden, suggesting genetic or unrecognized factors.

Cerebroplacental Ratio as a Predictor of Perinatal Outcome in Hypertensive Disorders of Pregnancy and Its Comparison With Its Constituent Doppler Indices

Objective Doppler velocimetry is an established method of antepartum fetal surveillance in pre-eclampsia. Cerebroplacental ratio detects the centralization of fetal blood flow and the insufficiency in placental circulation. It is postulated to be a better marker of perinatal outcome than either vessel Doppler alone. The current study aims to assess the cerebroplacental ratio as a predictor of adverse perinatal outcomes and compare it to the systolic/diastolic (S/D) ratio of umbilical artery (UA) and middle cerebral artery (MCA) in hypertensive disorders of pregnancy. Material and methods The present prospective observational cohort study included 100 patients with hypertensive disorders of pregnancies between 32 and 37 weeks. Ultrasound with Doppler was done and the following parameters were assessed: fetal biometry, amniotic fluid index, umbilical artery pulsatility index, middle cerebral artery pulsatility index, S/D ratio of umbilical artery, S/D ratio of middle cerebral artery, and cerebroplacental ratio. Sensitivity, specificity, positive and negative predictive values were calculated for the cerebroplacental ratio and S/D ratios of umbilical and middle cerebral arteries. McNemar's test was used for the comparison of sensitivity and specificity. Results Thirty-two patients had an abnormal cerebroplacental ratio. Adverse perinatal outcomes such as a cesarean section for fetal distress, small for gestational age, APGAR < 7 at 1 and 5 minutes, NICU admission, and perinatal mortality were more in the group with abnormal cerebraplacental ratio and the difference was statistically significant. Conclusion The cerebroplacental ratio is a more reliable predictor of adverse perinatal outcomes and should be routinely calculated during obstetrical Doppler for antepartum fetal surveillance in case of hypertensive disorders of pregnancy.
It suggested that the cerebroplacental ratio may be calibrated in the software of
the Doppler ultrasonography machine for routine use in high-risk pregnancies.

Neurodevelopment of infant with late fetal growth restriction

Late fetal growth restriction has increasingly gain interest. Differently from early fetal growth restriction, the severity of this condition and the impact on perinatal mortality and morbidity is less severe. Nevertheless, there is some evidence to suggest that fetuses exposed to growth restriction late in pregnancy are at increased risk of neurological dysfunction and behavioral impairment. The aim of our review was to discuss the available evidence on the neurodevelopmental outcome in fetuses exposed to growth restriction late in pregnancy. Cerebral blood flow redistribution, a Doppler hallmark of late fetal growth restriction, has been associated with this increased risk, although there are still some controversies. Currently, most of the available studies are heterogeneous and do not distinguish between early and late fetal growth restriction when evaluating the long-term outcome, thus, making the correlation between late fetal growth restriction and neurological dysfunction difficult to interpret. The available evidence suggests that fetuses exposed to late growth restriction are at increased risk of neurological dysfunction and behavioral impairment. The presence of the cerebral blood flow redistribution seems to be associated with adverse neurodevelopmental outcome, however, from the present literature the causality cannot be ascertained.

No. 197a-Fetal Health Surveillance: Antepartum Consensus Guideline

OBJECTIVE

This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum care in Canada.

OPTIONS

Consideration has been given to all methods of fetal surveillance currently available in Canada.

OUTCOMES

Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered.

EVIDENCE

A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1).

SPONSOR

This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: FETAL MOVEMENT COUNTING: RECOMMENDATION 2: NON-STRESS TEST: RECOMMENDATION 3: CONTRACTION STRESS TEST: RECOMMENDATION 4: BIOPHYSICAL PROFILE: RECOMMENDATION 5: UTERINE ARTERY DOPPLER: RECOMMENDATION 6: UMBILICAL ARTERY DOPPLER.

Fetal hemodynamics and language skills in primary school-aged children with fetal growth restriction: A longitudinal study

AIM

Long-term follow-up studies on children born with fetal growth restriction (FGR) have revealed a specific profile of neurocognitive difficulties, including problems with speech, language and literacy skills. We hypothesized that problems with communication skills, including language use and literacy skills of FGR children at primary school age are associated with prenatal circulatory changes.

METHODS

Ultrasonographic assessment of fetoplacental hemodynamics was performed prenatally in 77 fetuses. After a follow-up period of 8-10 years, assessment of reading and spelling skills using standardized tests and the Children's Communication Questionnaire (CCC-2) was performed to measure different language skills in 37 FGR children and 31 appropriately grown (AGA) controls, matched for gestational age.

RESULTS

Increased blood flow resistance in the umbilical artery (UA PI >2 SD) during fetal life showed odds ratios of 3.5-19.1 for poor literacy and communication skills and need for speech and language therapy. Furthermore, FGR children with prenatal cerebral vasodilatation (cerebroplacental ratio (CPR) < -2 SD) had significantly poorer literacy and communication skills, at primary school age compared to the AGA controls. Abnormal CPR demonstrated odds ratios of 4.2-28.1 for poor literacy and communication skills and need for speech and language therapy.

CONCLUSION

Increased blood flow resistance in the umbilical artery and cerebral vasodilatation are associated with poor communication, language, and literacy skills at early school age in children born with FGR. These findings indicate the need for continuous follow-up of this group and timely targeted support to ensure optimal academic outcomes.

Neurodevelopmental outcomes at five years after early-onset fetal growth restriction: Analyses in a Dutch subgroup participating in a European management trial

OBJECTIVE

The objective of this study is to explore developmental outcomes at five years after early-onset fetal growth restriction (FGR).

STUDY DESIGN

Retrospective data analysis of prospective follow-up of patients of three Dutch centres, who participated in a twenty centre European randomized controlled trial on timing of delivery in early-onset FGR. Developmental outcome of very preterm infants born after extreme FGR is assessed at (corrected) age of five.

RESULTS

Seventy-four very preterm FGR children underwent follow-up at the age of five. Mean gestational age at birth was 30 weeks and birth weight was 910 g, 7% had a Bayley score <85 at two years. Median five years' FSIQ was 97, 16% had a FSIQ < 85, and 35% had one or more IQ scores <85. Motor score ≤ 7 on movement ABC-II (M-ABC-II-NL) was seen in 38%. Absent or reversed end-diastolic flow, gestational age at delivery, birthweight and neonatal morbidity were related to an FSIQ < 85. Any abnormal IQ scale score was related to birthweight, male sex and severity of FGR, and abnormal motor score to male sex and bronchopulmonary dysplasia (BPD).

CONCLUSIONS

Overall, median cognitive outcome at five years was within normal range, but 35% of the children had any abnormal IQ score at age five, depending on the IQ measure, and motor impairment was seen in 38% of the children. GA at delivery, birthweight, EDF prior to delivery and neonatal morbidity were the most important risk factors for cognitive outcomes.

Prognostic accuracy of cerebroplacental ratio for adverse perinatal outcomes in pregnancies complicated with severe pre-eclampsia; a prospective cohort study

OBJECTIVE

The current study aims to assess the efficacy of fetal middle cerebral artery/umbilical artery pulsatility index ratio (cerebroplacental ratio CPR) in predicting the occurrence of adverse perinatal outcomes in pregnancies complicated with severe pre-eclampsia.

MATERIALS AND METHODS

This cohort study included 100 pregnant women between 34 and 40 weeks of gestation attended the labor ward and diagnosed with severe pre-eclampsia. Doppler evaluation was carried out to measure the CPR. Apgar score and fetal umbilical artery pH were assessed within 5 min of delivery. The rate of neonatal intensive care unit (NICU) admission was obtained.

RESULTS

Apgar score at 5 min >7 was in 82 cases (82%) and 12 cases (12%) scored < 7. Fetal blood PH was >7.2 in 67% of cases while 33% of cases had PH <7.2. As regard the NICU admission; 66% of neonates did not need admission while 34% of neonates were admitted to the NICU. There was a significant association between CPR and low Apgar score at 5 min (P < 0.001). The sensitivity of CPR in detection of Apgar score <7 was 50%, and specificity 88.1%. CPR had a poor predictive value of the low umbilical artery PH <7.2 (P = 0.318) with 43.75% sensitivity and 69.05% specificity. There was a significant association between CPR and NICU admission (P = 0.009).

CONCLUSIONS

Adding CPR ratio to routine antepartum fetal surveillance from 34 weeks gestation may help with patient counseling regarding adverse neonatal outcomes for women with severe pre-eclampsia as there is a strong correlation between it and adverse neonatal outcomes.

Physiological adaptation of the growth-restricted fetus

The growth-restricted fetus in utero is exposed to a hostile environment and suffers undernutrition and hypoxia. To cope with the stress, the fetus changes its physiological functions. These adaptive changes aid intrauterine survival; however, they can lead to permanent functional and structural changes that can contribute to the development of serious chronic diseases later in life. Epigenetic mechanisms are an important part of the pathophysiological processes behind this "developmental origin of adult diseases." The dominant cardiovascular adaptive change is the redistribution of blood flow in hypoxic fetuses, with preferential supply of blood to the fetal brain, myocardium, and adrenal glands. The proportion of blood from the umbilical vein to the ductus venosus and foramen ovale increases, which increases the cardiac output of the left heart ventricle. The increased perfusion of fetal brain can be followed with Doppler ultrasound as increased diastolic velocities and decreased pulsatility index in the middle cerebral artery.

Fetal brain-sparing after laser surgery for twin-twin transfusion syndrome appears associated with two-year neurodevelopmental outcomes

OBJECTIVE

The cerebroplacental ratio (CPR) is a semi-quantitative marker for fetal brain-sparing. Our purpose was to measure the CPR at the time of treatment with selective laser photocoagulation of communicating vessels in gestations with twin-twin transfusion syndrome (TTTS) to test its association with neurological outcomes at approximately 2 years.

METHODS

One-hundred children treated for TTTS with laser surgery underwent neurodevelopmental assessment at age 2 years (within 6 weeks) via the Battelle Developmental Inventory 2nd Edition (BDI-2). The CPR was obtained 24 h before and after laser surgery. An abnormal CPR was categorically defined at <1.0. Multilevel linear regression was used to evaluate associations between CPR and neurodevelopment as assessed by the BDI-2.

RESULTS

Ninety-nine children had data available for analysis: 55 (56%) had normal CPR prior to laser surgery, and 62 (63%) had normal CPR following surgery. Post-laser CPR <1.0 was a risk factor for lower BDI-2 scores at age 2 years [98.1 (SD 11.5) vs 103.4 (SD 12.3) vs β = -0.23, p = 0.01]; this relationship remained significant after controlling for pre-surgical CPR and Quintero stage (adjusted β = -0.25, p = 0.01).

CONCLUSIONS

In this population, an abnormal CPR was associated with poorer 2-year neurodevelopmental outcomes. © 2015 John Wiley & Sons, Ltd.

Doppler for growth restriction: the association between the cerebroplacental ratio and a reduced interval to delivery

OBJECTIVE

Evaluation of the cerebroplacental ratio (CPR) as an adjunct to umbilical artery Doppler (UA) to assess risk of delivery before 32 weeks and/or delivery within 2 weeks from diagnosis of fetal growth restriction (FGR).

STUDY DESIGN

In a cohort of fetuses with suspected FGR, UA Doppler was performed, and when abnormal the CPR was calculated (middle cerebral pulsatility index/umbilical artery pulsatility index). Doppler characteristics were used to determine three study groups: (1) normal UA, (2) abnormal UA with normal CPR and (3) abnormal UA with abnormal CPR. The primary outcomes were delivery before 32 weeks and delivery within 2 weeks. Adjusted odds ratio (aOR) with 95% confidence intervals (CIs) were calculated controlling for maternal age, chronic hypertension and tobacco use. We performed a linear regression analysis comparing the value of the CPR with the gestational age at delivery. Kaplan-Meier survival curve analysis with log-rank tests for probability was performed.

RESULTS

We included 154 patients: 91, 31 and 32 in Group 1, 2 and 3, respectively. Subjects in Group 3 had higher rates of the two primary outcomes: there was a fivefold increased risk (aOR=5.2 (95% CI=2.85-9.48)) for delivery before 32 weeks and over a fourfold increased risk for delivery within 2 weeks (aOR=4.76 (95% CI=2.32-9.76)) compared with those with a normal CPR (Group 1). In contrast, subjects in Group 2 (abnormal UA Doppler but normal CPR) had a similar rate of delivery before 32 weeks (aOR=1.16 (95% CI=0.55-2.48)) and within 2 weeks (aOR=1.07 (95% CI=0.43-2.69)). The median gestational age at delivery was 36, 36 and 29 weeks in Groups 1, 2 and 3, respectively (P<0.001). Linear regression analysis revealed a strong correlation between the value of the CPR and gestational age at delivery: R(2)=0.56, correlation coefficient=0.75. Kaplan-Meier analysis revealed a significantly decreased latency to delivery in Group 3, as opposed to Groups 1 and 2 (Cox-Mantel hazard ratio (HR) of Group 2 versus Group 1 HR=1.20 (95% CI=0.78-1.83) and Group 3 versus Group 1 HR=5.00 (95% CI=2.4-10.21)).

CONCLUSION

The CPR differentiates those fetuses with suspected growth restriction most at risk for delivery before 32 weeks and delivery within 2 weeks from those likely to have a more prolonged latency until delivery is required. In patients with suspected FGR and an abnormal UA, the CPR can be used to guide management decisions, such as maternal hospitalization and/or transport, aggressive fetal monitoring and antenatal corticosteroid administration.

Estimation of the growth rate in fetuses with an abnormal cerebroplacental ratio compared to those with suspected growth restriction without evidence of centralization of blood flow

OBJECTIVES

To evaluate the growth rate in fetuses with suspected growth restriction according to their Doppler characteristics.

METHODS

A retrospective cohort of fetuses with suspected growth restriction was identified. We reviewed umbilical artery and middle cerebral Doppler pulsatility indices and calculated the cerebroplacental ratio. Three study groups were determined: (1) normal umbilical artery Doppler findings; (2) abnormal umbilical artery findings with a normal cerebroplacental ratio; and (3) abnormal umbilical artery findings with an abnormal cerebroplacental ratio. The primary outcome was the growth rate as estimated by fetal biometry from serial sonographic evaluations. Analysis of the mean growth rate in each study group was performed by analysis of variance. In addition, linear regression analysis comparing the cerebroplacental ratio to the growth rate was performed.

RESULTS

Fetal growth restriction was suspected in 416 patients; 176 patients were included in this analysis: 113, 38, and 25 in groups 1, 2, and 3 respectively. The estimated mean (SD) growth rate in group 3 was significantly lower than in groups 1 and 2: 8.3 (4.4) versus 19.6 (6.0) and 18.6 (7.7) g/d, respectively (P < .001). Linear regression analysis revealed a strong correlation between the growth rate and cerebroplacental ratio (r = 0.76; R(2) = 0.58) as well as the birth weight and cerebroplacental ratio (r = 0.78; R(2) = 0.61).

CONCLUSIONS

In fetuses with suspected growth restriction and abnormal umbilical artery Doppler findings, an abnormal cerebroplacental ratio is strongly associated with reduced fetal growth. In contrast, if the cerebroplacental ratio is normal, even in the setting of abnormal umbilical artery Doppler findings, fetuses grow similarly to those with normal umbilical artery findings.

Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia

OBJECTIVE

To study the association between the cerebroplacental ratio (CPR) and the development of pre-eclampsia.

STUDY DESIGN

Three study groups were determined: Group 1-normal umbilical artery (UA; referent), Group 2-abnormal UA and normal CPR and Group 3-abnormal UA and an abnormal CPR. The primary outcome was the development of severe pre-eclampsia.

RESULTS

We included 270 women. Women in Group 3 had significantly elevated rates of severe pre-eclampsia versus those in Group 1 and Group 2, 52.5% versus 5.1% and 15.4%, respectively, (P<0.01), adjusted odds ratio 4.14 (95% confidence interval, 2.59 to 6.61). Kaplan-Meier analysis revealed earlier delivery in women with pre-eclampsia in Group 3 versus Group 1, Cox-Mantel hazard ratio 2.39 (1.17 to 4.88), log rank P=0.01.

CONCLUSION

An abnormal CPR is associated with a higher rate severe pre-eclampsia with delivery at earlier gestational ages than with a normal UA or an abnormal UA, but normal CPR.

Neurodevelopment after fetal growth restriction

Fetal growth restriction (FGR) can emerge as a complication of placental dysfunction and increases the risk for neurodevelopmental delay. Marked elevations of umbilical artery (UA) Doppler resistance that set the stage for cardiovascular and biophysical deterioration with subsequent preterm birth characterize early-onset FGR. Minimal, or absent UA Doppler abnormalities and isolated cerebral Doppler changes with subtle deterioration and a high risk for unanticipated term stillbirth are characteristic for late-onset FGR. Nutritional deficiency manifested in lagging head growth is the most powerful predictor of developmental delay in all forms of FGR. Extremes of blood flow resistance and cardiovascular deterioration, prematurity and intracranial hemorrhage increase the risks for psychomotor delay and cerebral palsy. In late-onset FGR, regional cerebral vascular redistribution correlates with abnormal behavioral domains. Irrespective of the phenotype of FGR, prenatal tests that provide precise and independent stratification of risks for adverse neurodevelopment have yet to be determined.

Postnatal neuro-development of fetuses with absent end-diastolic flow in the umbilical artery and/or fetal descending aorta

OBJECTIVE

To determine whether absence of end-diastolic flow in the umbilical artery and/or fetal aorta impacts postnatal neuro-development in preterm-born children.

METHODS

The study group, consisting of 43 fetuses with absent end-diastolic flow in the umbilical artery and/or fetal aorta, was compared with a control group, consisting of 30 fetuses, matching for gestational age but with normal doppler-flow results. The children's neuro-developmental status was assessed using the 'Munich functional developmental diagnostics' (MFDD), between the 2nd and 3rd year of life.

RESULTS

Gestational age at birth was 33 + 6 weeks in the study group and 34 + 4 weeks in the control group. A brain-sparing effect was observed in 37.3% of fetuses in the study group compared with 10.0% in the control group (p = 0.014). For all seven MFDD domains, the number of children with deficiencies was higher in the study group. For the domains perception, active speech and comprehension this effect was statistically significant (p < 0.05). Overall, 30.2% of children in the study group and 16.7% of the control group had pathologic test results (p < 0.013).

CONCLUSION

Pathological doppler-flow in the umbilical artery and/or fetal descending aorta in preterm born children is associated with neuro-developmental deficiencies. Intensive pediatric care is recommended to mitigate these deficiencies during early childhood.

Neurodevelopment following fetal growth restriction and its relationship with antepartum parameters of placental dysfunction

Placental dysfunction leading to fetal growth restriction (FGR) is an important risk factor for neurodevelopmental delay. Recent observations clarify that FGR evolves prenatally from a preclinical phase of abnormal nutrient and endocrine milieu to a clinical phase that differs in characteristics in preterm and term pregnancies. Relating childhood neurodevelopment to these prenatal characteristics offers potential advantages in identifying mechanisms and timing of critical insults. Based on available studies, lagging head circumference, overall degree of FGR, gestational age, and umbilical artery (UA), aortic and cerebral Doppler parameters are the independent prenatal determinants of infant and childhood neurodevelopment. While head circumference is important independent of gestational age, overall growth delay has the greatest impact in early onset FGR. Gestational age has an overriding negative effect on neurodevelopment until 32-34 weeks' gestation. Accordingly, the importance of Doppler status is demonstrated from 27 weeks onward and is greatest when there is reversed end-diastolic velocity in the UA or aorta. While these findings predominate in early-onset FGR, cerebral vascular impedance changes become important in late onset FGR. Abnormal motor and neurological delay occur in preterm FGR, while cognitive effects and abnormalities that can be related to specific brain areas increase in frequency as gestation advances, suggesting different pathophysiology and evolving vulnerability of the fetal brain. Observational and management studies do not suggest that fetal deterioration has an independent impact on neurodevelopment in early-onset FGR. In late-onset FGR further research needs to establish benefits of perinatal intervention, as the pattern of vulnerability and effects of fetal deterioration appear to differ in the third trimester.

Cognitive function after intrauterine growth restriction and very preterm birth

OBJECTIVE

To evaluate the effects of intrauterine growth restriction (IUGR) with absent or reversed end-diastolic blood flow in the umbilical artery and very preterm birth on cognitive outcome at 5 to 8 years of age.

METHODS

We studied 34 children with IUGR born at a median of 26.9 gestational weeks (GWs) (range: 24-29 GWs) (PT-IUGR), 34 matched preterm appropriate-for-gestational age (PT-AGA) children, and 34 term AGA children (T-AGA) by using the Wechsler Preschool and Primary Scale of Intelligence, Wechsler Intelligence Scale for Children, Strengths and Difficulties Questionnaire, and Brown's attention-deficit disorder (ADD) scales.

RESULTS

The PT-IUGR group had mean (SD) scores on the verbal IQ (VIQ) and full-scale IQ (FSIQ) of 83.8 (17.3) and 78.9 (16.6), respectively, compared with the PT-AGA group, which had scores of 96.0 (14.5) and 90.1 (14.2) (P = .003 and P < .007), and the T-AGA group, which had scores of 101.3 (12) and 102.9 (13.2) (P < .001 and P < 001), respectively. The VIQ difference remained significant after adjustment for parental level of education, gestational age at birth, and neonatal morbidity. Performance IQ (PIQ) did not differ between the PT-IUGR and PT-AGA groups; their mean PIQs were lower than that of the T-AGA group (P < .001). Boys in the PT-IUGR group scored lower than girls in VIQ and FSIQ (P = .005 and .007, respectively). Behavior and ADD scores did not differ between the preterm groups.

CONCLUSIONS

Children born very preterm after IUGR have an increased risk for cognitive impairment at early school age compared with children delivered very preterm for other reasons. Differences in cognitive outcome were restricted to boys who may have been especially vulnerable to the influence of IUGR and very preterm birth.

Severe early onset pre-eclampsia: prognostic value of ultrasound and Doppler assessment

OBJECTIVE

Assess the prognostic value of ultrasound and Doppler parameters in severe preterm pre-eclampsia.

STUDY DESIGN

Prospective cohort study in Cape Town, South Africa, involving 113 women with severe pre-eclampsia between 24 and 34 weeks of gestation and managed expectantly when suitable. Serial ultrasound and multivessel Doppler assessments were performed 2 to 3 times weekly. Observations included fetal weight estimation, growth pattern, amniotic fluid volume, appearance of the heart and bowel, pulsatility index of the uterine, umbilical and middle cerebral arteries and ductus venosus. Perinatal outcome (death or neurological compromise, n=12) and major morbidity (n=62) were related to findings at recruitment and on the last assessment preceding delivery.

RESULTS

In univariate analysis, fetal growth asymmetry and waveform analysis of all three fetal vessels significantly correlated with both end points. The initial fetal weight estimation with a cutoff weight of 1080 g had the highest sensitivity (83.3%) and negative predictive value (97.5%) for poor outcome (P<0.001) while the final ductus venosus pulsatility index had the highest specificity (92%) and positive predictive value (33%). The combination of a raised placentocerebral ratio and ductus venosus pulsatility index close to delivery had the highest (57.1%) positive predictive value. Logistic regression showed the best overall predictive model for poor outcome to be a combination of initial fetal weight estimation and final ductus venosus pulsatility index (overall accuracy 94.6%, RR 20.20 (7.36, 55.41)). The initial fetal weight estimation with a cutoff weight of 1283 g provided the best correct prediction of major morbidity (83.2% overall accuracy, sensitivity 79.0%, specificity 88.2%, positive and negative predictive values of 89.1 and 77.6% respectively). This was better than using the gestational age at recruitment or delivery, birth weight or any of the Doppler results. The prediction of morbidity was not improved by the addition of any other variable in logistic regression analysis.

CONCLUSION

For the short-term outcome measures assessed in this study, the estimated fetal weight at the time of diagnosis is the most important prognostic factor in severe pre-eclampsia with some additional value of ductus venosus assessment.

Minor neurological dysfunction, cognitive development and somatic development at the age of 3 to 11 years in very-low-birthweight infants with transient periventricular echodensities

AIM

To determine, using strict exclusion criteria, whether transient periventricular echodensities (TPE) in very-low-birthweight infants lead to minor neurological dysfunction and problems in cognitive and somatic development in children without major neurological impairments.

METHODS

23 children with TPE were matched to 23 children without TPE. Exclusion criteria were small for gestational age, microcephaly at birth, diplegia, asphyxia, psychomotor retardation, intraventricular haemorrhage grade III/IV, major surgical interventions and malformations. The Kaufman Assessment Battery for Children, Draw-a-Man Test and neuropaediatric examination were used for evaluation.

RESULTS

There were no differences in demographic data, growth and socio-economic status. Significant differences with lower results in the TPE group were found in fine motor skills and in the Draw-a-Man Test. In the Kaufman Assessment Battery for Children, all subscales were below average in the TPE group, except the sequential processing scale. In the control group, all subscales were within the average range.

CONCLUSION

By using strict exclusion criteria to eliminate other risk factors for minimal neurological dysfunction and poor cognitive development, we were able to focus on the effect of TPE. TPE seem to affect cognitive development and cause minor neurological dysfunction.

Prognostic value of umbilical-middle cerebral artery pulsatility index ratio in fetuses with growth restriction

OBJECTIVE

To study the utility of Doppler velocimetry and computerized cardiotocography in the management of intrauterine growth restriction and prediction of neonatal outcome.

PATIENTS AND METHODS

Seventy-two pregnant women with fetuses showing growth restriction and delivered within 48 h of their last Doppler velocimetry evaluation. The last computerized cardiotocographic trace from these fetuses was used for statistical analysis, and the last trace from the healthy fetuses of 93 consecutive women undergoing cesarean section was used as control. Umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), UA PI/MCA PI ratio, and uterine artery resistance index (Ut RI) were assessed.

RESULTS

Among women with growth-restricted fetuses, all parameters were significantly higher in those who had hypertension; and in those who had diabetes, only the UA PI/MCA ratio was significantly higher. Umbilical artery PI values and the UA PI/MCA ratio were higher in those who had a nonreassuring result to computerized nonstress test immediately before delivery. A multiple logistic analysis showed that the UA PI/MCA ratio was the only Doppler velocimetry parameter predicting cardiotocographic nonreactivity; furthermore, the predictivity of extended newborn hospitalization (longer than 15 days) was verified, with a sensitivity of 56% and a specificity of 92% when the ratio was higher than 1.26.

CONCLUSION

The MCA PI of fetuses with growth restriction should be assessed. The UA PI/MCA ratio is predictive of a nonreactive computerized cardiotocography trace and of prolonged neonatal hospitalization.

Minor neurological dysfunction, cognitive development, and somatic development at the age of 3 to 7 years after dexamethasone treatment in very-low birth-weight infants

The objective of this study was to assess minor neurological dysfunction, cognitive development, and somatic development after dexamethasone therapy in very-low-birthweight infants. Thirty-three children after dexamethasone treatment were matched to 33 children without dexamethasone treatment. Data were assessed at the age of 3-7 years. Dexamethasone was started between the 7th and the 28th day of life over 7 days with a total dose of 2.35 mg/kg/day. Exclusion criteria were asphyxia, malformations, major surgical interventions, small for gestational age, intraventricular haemorrhage grades III and IV, periventricular leukomalacia, and severe psychomotor retardation. Each child was examined by a neuropediatrician for minor neurological dysfunctions and tested by a psychologist for cognitive development with a Kaufman Assessment Battery for Children and a Draw-a-Man Test. There were no differences in demographic data, growth, and socio-economic status between the two groups. Fine motor skills and gross motor function were significantly better in the control group (p<0.01). In the Draw-a-Man Test, the control group showed better results (p<0.001). There were no differences in development of speech, social development, and the Kaufman Assessment Battery for Children. After dexamethasone treatment, children showed a higher rate of minor neurological dysfunctions. Neurological development was affected even without neurological diagnosis. Further long-term follow-up studies will be necessary to fully evaluate the impact of dexamethasone on neurological and cognitive development.